Why Can't We Be Sad?

Today's New York Times Magazine has a really interesting article by Jonah Lehrer called "Depression's Upside." Mr. Lehrer talks about a possible evolutionary purpose for Major Depression.

Mr. Lehrer writes:

The persistence of this affliction — and the fact that it seemed to be heritable — posed a serious challenge to Darwin’s new evolutionary theory. If depression was a disorder, then evolution had made a tragic mistake, allowing an illness that impedes reproduction — it leads people to stop having sex and consider suicide — to spread throughout the population. For some unknown reason, the modern human mind is tilted toward sadness and, as we’ve now come to think, needs drugs to rescue itself.

The alternative, of course, is that depression has a secret purpose and our medical interventions are making a bad situation even worse. Like a fever that helps the immune system fight off infection — increased body temperature sends white blood cells into overdrive — depression might be an unpleasant yet adaptive response to affliction. Maybe Darwin was right. We suffer — we suffer terribly — but we don’t suffer in vain.

So I didn't like the article at the beginning; it relied on anecdotes--the woman who felt so much better with antidepressants that she'd grown complacent in a bad marriage, for example. It doesn't capture all the patients I see, and any way you dice it, if you end up dead from suicide, your productivity comes to a halt. It seems to me that there are some people who suffer in ways that these anecdotes don't explain. I suppose, however, even if we assume that depression is an unproductive, tormenting state, when it ends, is there something to be gained from having gone through it. Lehrer tells us, "Wisdom isn't cheap, and we pay for it with pain." I, personally, think there remains a differentiation between pain and major depression, and that perhaps one can grow through all sorts of suffering, and I'm all in favor of finding my own personal path to wisdom in ways that might not entail so much suffering. Just a thought.

But I ultimately, I liked the article because Lehrer, while clearly a proponent of the "don't mess with evolution, less drugs, please," school of thought, presents a balanced view. He gives Peter Kramer (Listening to Prozac) a voice, and talks about the objections to the viewpoint he puts forth. He describes a theory that depression is evolutionarily helpful because of the ruminative nature of the illness. He also cues us in that this is just one explanatory theory which remains unproven, and there are others. Lehrer continues:

Other scientists, including Randolph Nesse at the University of Michigan, say that complex psychiatric disorders like depression rarely have simple evolutionary explanations. In fact, the analytic-rumination hypothesis is merely the latest attempt to explain the prevalence of depression. There is, for example, the “plea for help” theory, which suggests that depression is a way of eliciting assistance from loved ones. There’s also the “signal of defeat” hypothesis, which argues that feelings of despair after a loss in social status help prevent unnecessary attacks; we’re too busy sulking to fight back. And then there’s “depressive realism”: several studies have found that people with depression have a more accurate view of reality and are better at predicting future outcomes. While each of these speculations has scientific support, none are sufficient to explain an illness that afflicts so many people. The moral, Nesse says, is that sadness, like happiness, has many functions.

The article finishes off with the idea that people in depressive states are better thinkers, they notice more, they work better. He talks about a study that shows that on gloomy days with dismal music playing, shoppers notice more trinkets by the cash register. Gloomy weather and oppressive music might set a low mood tone, but this seems a far cry from an episode of major depression, and not something that is generalizable to anything more than clouds and music and trinkets. There's a second study mentioned of undergrads doing an abstract reasoning test that shows people with a "negative mood" perform or focus better; again, it falls short of being a comparison for major depression. The shrinks among us find it hard to imagine that 'negative moods' and Major Depression are all that linked. Everyone has negative moods. Not everyone has major depression.

What about the studies that link mood disorders and creative tendencies? This does seem likely, and we're left to wonder (my own thoughts, not the article) if the intense experience of an episode of mood disturbance either fuels creativity by feeding it material or requiring a release, or if the genetics are wired such that mood disorders and artistic talents might be coded near one another.

You thoughts?

Let The Sun Shine!!!

We've had 80 (?) inches of snow here this year. Unheard of! Who moved that Mason-Dixon line? It was enchanting at first, and I felt like I was on vacation: fires, hot cocoa, no where to go, watch a movie, eat good food, for a day or two here and there I couldn't get to work and no one wanted to see me. Snow Day!

Ah, but the enchantment ended. The bushes are flattened. The gutter are draped across my house leaving rotted beams exposed. The snow is in ugly blackened mounds everywhere, and as it gradually melts, there are tracks of mud pretty much every where.

And today's forecast: snow. Yesterday they were saying 5 to 10 inches. Two patients have called to cancel (Shrink response: Call me in the morning after you look out the window). So far, so good. Hoping the gutter guys can come today.

Enough hot cocoa. Enough days off. Enough trying to reschedule everyone. Enough shoveling, Enough salt tracked onto the wooden floors. Enough. Enough. (I know, it could be much worse).

Here's to 75 and sunny, somewhere?

A Movie For ClinkShrink

Perhaps the most disturbing movie I've ever seen.

So we start with the ferry ride to Shutter Island where two federal agents are headed to a a particularly creepy hospital for the criminally insane to search for an escapee--- a mother who drowned her three children and who has now "evaporated" from her locked cell. The story revolves around the haunted character of Teddy Daniels (Leonardo DiCaprio) whose flashbacks and dreams pave the story: his role in the liberation of a Nazi death camp & the horrifying death of his young wife in a fire. The movie is dark, it is set on an island during a hurricane, in a hospital built during the Civil War, with Ben Kingsley in a bow tie playing the polite but devious head psychiatrist. In every scene, things are falling: rain, snow, papers swirling, ashes, unknown particles. It's compelling and confusing, all at the same time. The plot twists and weaves, and by the end the reality was a bit of a jumble. What really happened? We didn't agree, and when we caught dinner after, the couples at the next table were having the same discussion.

Not exactly a positive view of psychiatry, but this one was so much about the twists of the plot, that it hardly seems worth worrying about the portrayal of our profession. And "disturbing" : the storyline itself was not terribly disturbing, but the images of dead children left me very unsettled. I'll leave the full analysis to ClinkShrink....and no plot spoilers here.

Medical Marijuana on KevinMD

Lockup doc gave us the head's up that KevinMD is also talking about the legalization of marijuana for medical uses. He has good discussion of the issues up, do check it out: Medical Marijuana has Doctors Asking Questions. How'd he know I was asking about this?

The summary comes from HCPLive:

In January, New Jersey became the 14th state in the nation to legalize marijuana use for certain chronic illnesses. Other states where the use of medical marijuana is permitted include Alaska, California, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Oregon, Rhode Island, Vermont, and Washington; around a dozen more states are weighing pending bills.

The New Jersey law is the most restrictive in the nation and authorizes prescribed marijuana for only a handful of chronic illnesses, such as multiple sclerosis, cancer, glaucoma, epilepsy, Crohn’s disease, AIDS, muscular dystrophy and Lou Gehrig’s disease. Unlike other states, physicians in New Jersey will not be able to prescribe medical marijuana for anxiety, headaches, or chronic pain.

It goes on to discuss the lack of evidence to support uses for medical marijuana, and the obstacles to research:

Despite the Obama administration’s relaxation on prosecutions, many researchers are still having difficulty getting approval to conduct studies that involve smoking marijuana. Requests to conduct the studies must go through the National Institute on Drug Abuse (NIDA), which controls supply from a plantation at the University of Mississippi, the only federally approved source of marijuana. NIDA routinely turns down study requests unless they are designed to evaluate the potential harm from smoking marijuana. The Drug Enforcement Agency has also declined petitions from researchers requesting permission to grow their own marijuana for use in studies.

The article notes that there are some continued issues:

Most states with medical marijuana laws allow employers to refuse employment to individuals who use medical marijuana. In some states, like Colorado, the laws are ambiguous and employers are unclear as to whether they can forbid employees to use medical marijuana outside of work. Schools are also grappling with the issue, as well, with more high school students—particularly in areas with less restrictive medical marijuana laws—receiving prescriptions for marijuana, increasingly to treat ADHD. In addition, some facilities that perform organ transplants acknowledge denying transplants to patients who use medical marijuana.

In the absence of any proven benefits from smoking marijuana, physicians in the 14 states where it is legal may want to discuss some of the pros and cons with their patients prior to issuing a prescription. Patients need to be aware of the potential impact of medical marijuana on all facets of life and should be wary of letting the anecdotal hype surrounding medical marijuana use dissuade them from first trying a proven treatment option.

View the discussion on HCPLive.com.

________________

On another note, Rach asked us to post the following:

Stan Kutcher at Dalhousie University (Halifax, NS) is asking Canadians for feedback on how to improve infant, child and youth mental health services via an anonymous survey.

https://surveys.dal.ca/opinio/s?s=7808

Going to Pot (or Let's Talk about Medical Marijuana)

Our state is considering legalizing medical marijuana.

As a psychiatrist, my first thought is : NO! We treat addictions, and we try hard not to cause them. Marijuana (and many other illegal substances) may help mood and anxiety in the moment, but they don't seem to fix things for the long haul. And chronic pot smoking decreased motivation, burbles your brain, and does nothing good to your lungs. I have visions of patients at the door saying they need me to prescribe pot for their anxiety. Please, doctor, please.

But then I think of end-stage cancer patients, and it really doesn't bother me if a little cannabis helps with their symptoms.

There are those who claim that oral THC (marinol) can be helpful for many symptoms, oh, but unliked the smoked stuff, Marinol doesn't get you high. There's less evidence about inhaled marijuana being effective.

So here's my question: How does medical marijuana work in your state? How widespread is the use? What are the terms and conditions under which it can be prescribed? Who gets it and with what regulation? Is it a good thing or a bad thing and why? And please, if you have links to data or studies or interesting articles about the legalization of medical marijuana, by all means put them in your comments. If you want to tell me why cannabis should be legal and it's a government plot to keep it illegal and any information from NORML, you can hold off on those links...I think I've heard that side of the story.

Are In-Network Shrinks Better Shrinks?

Clink and I have been having a discussion about insurance participation. It's for the book. We think.

So I've made the statement that given that insurance companies reimburse according to their somewhat random (and generally reduced) rate of Usual & Customary Fees, that they require paperwork and hoops to jump through, and that there is financial incentive for seeing a lot of patients in less time, more so then in giving slow and thoughtful care, that in some communities there is a force of natural selection and that the Best docs may be the ones who won't participate in insurance networks. Is this completely true: of course not. Some really good docs (especially inpatient and consult-liason, where there is very little option) participate with insurance companies. Maybe they live in communities where it's the only feasible way, maybe they like having high-volume practices, maybe they just participate with one or two selected insurance companies to accommodate select patients (or because they've heard the company is easy to work with, or reimburses well), or maybe they feel it's the socially responsible thing to do. Oh, or maybe they worry that if they Don't, they won't get enough referrals and make it in private practice.

So, in thinking about this, I realized I know very little about docs who participate with insurance networks. None of my friends do. I participated in Blue Cross for 7 years---they never sent me referrals and they'd send me random checks for $12.44 (like what was that a portion of?) or $44 something. The UCR was different for each patient, and they were all much much less than going fees back then.

I've been assuming that to make a living accepting insurance, that the doc needs to see a high volume of patients. That's not to say that a psychiatrist might not be willing to see a portion of their practice as psychotherapy patients and take a lower hourly fee for that, and compensate by doing high volume work the rest of the day, or by offering different levels of care based on insurance. That's not to say that there aren't psychiatrists who don't participate with insurance but still have very high volume practices, but they make a lot more money then I do (or so I believe).

But it's occurred to me that I really don't know much beyond what I learned when I was in a group practice way back when. If you take health insurance, tell me how your practice works-- how many patients do you see in an hour, do you get paid from the insurance companies, do you like your work, do you feel the care you give is as good? And if you see a psychiatrist in your insurance network, please tell us how that goes....how long are the appointments, how often do you go in, how does the billing and co-pay work? And if you've seen both in- and out- of network shrinks, how were they different and what worked better for you?

Academy for Film and Psychiatry

There's nothing quite like blogging in a blizzard. My house, by the way, is the one with the gutters torn off one side and draped across the front with the disconnected downspouts. You will notice that our flat roofs have been shoveled off-- makes for a fine family project in the snow-- after having the insight that another 20 inches could well cause their collapse.

So I thought I'd give a plug to Dr. Fred Miller and his Academy for Film and Psychiatry. His 'filmosophy' reads:

FILM IS NOTHING SHORT OF OUR STRUGGLE TO UNDERSTAND PEOPLE, CULTURE AND OURSELVES. FILM ENGAGES ALL OF OUR SENSES AND IN THAT WAY IS LIKE NO OTHER MEDIUM. THE PARALLELS BETWEEN THE FILMMAKER AND THE PSYCHOTHERAPIST ARE MANY. EACH IS ACUTELY AWARE (OR SHOULD BE) THAT HE OR SHE IS PRESENTING AN UNDERSTANDING OF THE HUMAN CONDITION AND ALSO THAT THE PROCESS OF UNDERSTANDING IN AND OF ITSELF IS HEALING AND FULFILLING. BOTH ARE SUBJECTS OF INTENSIVE STUDY AND ENDLESS DEBATE. ENJOY!

Film seems like as a good a thing as any to do today, so long as the power holds. Brrrr from Maryland, hon!

What's A Psychiatric Emergency?

People have been writing in to respond to my Emergency! post and asking what constitutes an emergency in psychiatry. Some people are worried that I'll be taken advantage of if I'm too easy to schedule emergent appointments.

So what's a psychiatric emergency?

First, let me say that by design, I keep my life a little loose. I don't like scheduling far in advance, I don't have a secretary, I try to be accommodating and mostly this works for me. Once in a great while I feel like people are playing musical appointments and I vaguely wish it weren't so, but you can't have your cake and eat it to (unless you buy two cakes, and that might well be an option). So people who miss a lot of appointments, I tell them to call when they want to come in. You want to return in 3 months? You think I know my schedule 3 months in advance? 4-6 weeks, that's it, so call when you want to come in. I may call you and shift things. I'll be nice when you call me to shift things. So when someone calls and wants to come, it's usually fine--it's how I work my life, and it's how I make my living. No one ever calls and says "It's an emergency." What they say is "can I come in today, I'm really upset" and if I have the time, I wouldn't refuse it to make some point --hmmm what would that point be?. My post was more about the person who calls with a request for an urgent appointment who then doesn't accept the time offered. People call me because life is distressing them, and that's fine. I don't typically tell patients to go to the ER, but I don't call "I'm upset" an emergency. How often does this happen? Rarely. And I suppose I believe that part of the trade off for a no-insurance, pay-up-front doc is that I'm available, and offer a degree of availability and reachability beyond what is offered in a 9-5 clinic or from a doc with a caseload of hundreds.

So what's an "emergency?" Some things in psychiatry are clearly an emergency:

• Suicidal thoughts or homicidal thoughts that might be acted on. Chronic suicidal ideation in someone who is certain they will not take action on is not an emergency.

• Command hallucinations telling the patient to hurt themselves or others where the patient does not clearly identify this as something chronic and ongoing that he certain he wouldn't listen to.

• The acute onset of psychosis, especially if it leads to bizarre behavior. When someone is doing really usual things, it indicates that they are not differentiating reality from perceptual problems and they lose judgment and become completely unpredictable.

• Anyone walking around naked in public, for similar reasons.

• The acute onset of mania, because behavior can be unpredictable, dangerous, and expensive.

• Any life-threatening behavior, directed at oneself or others.

• Really uncomfortable side effects to medications, and sometimes this is best dealt with in an ER where medications to counter the side effects can be administered by injection.

• High fevers when a patient is on certain medications-- they can be indicative of a drop in white blood count for a patient on Clozaril or Tegretol, or of neuroleptic malignant syndrome for someone on neuroleptics.

• Severe anxiety or panic are not 'emergencies' but it would be hard to tell that to someone experiencing their first episode, it's terribly uncomfortable, and it can be confused with a heart attack-- this is one for the ER if there are cardiac symptoms and any doubt. Unless there's a negative cardiac work-up and a known history of panic attacks, calling a psychiatrist with chest pain, shortness of breath, and other cardiac symptoms makes no sense (call 911). Most patients with known panic disorder do not identify their episodes as emergencies.

• Really disorganized behavior-- it can be indicative of a psychosis, a delirium, or a drug intoxication.
• An overdose of any medication because it might lead to bad things shortly. Like death.
  

I may have missed some things, so do chime in.

Being upset about something bad that has happened is not a psychiatric "emergency", but if you can get hold of someone who can listen and say something comforting--- including a psychiatrist -- well, it's nice when that happens.

Mostly, I leave it to my patients to define when something is an emergency. I can't imagine it's every comforting to have someone say "now that's NOT an emergency."

TeleMental Health Services Needed

via HITshrink:




Two feet of snow and Baltimore comes to a screeching halt. How to get the doctors to the hospital? This is where telepsychiatry can be very helpful. However, there are still so many impediments to using telemedicine (billing, liability, documentation, technical) that we are *still* unable to use it when we need it. Like today, where the hospital will have to send a 4x4 to pick up Dr Chandran to get him to the hospital.

A broader term for distance mental health services is Telemental Health services, or TMH. Proposed new regulations were released last week that would permit and regulate TMH under the public mental health system (aka Medicaid) in Maryland. Unfortunately, the way it is currently written would not permit me to "see" inpatients on our unit from home during a blizzard. Still, it is a step in the right direction.

For more info on TMH, check out the Maryland Telemental Health website.

Emergency!

I often get calls from patients who want to come in "as soon as possible." Especially new patients, but sometimes established patients. I try to be as flexible and accommodating as possible, but sometimes it gets a bit inconvenient. Now I'm in confabulation mode, but I'm curious about readers' opinions of how one should respond to emergencies. Often, I offer an appointment asap and the person requesting it can't make it and asks for another time. So it becomes a bit of juggling of priorities. And I'm left wondering how much the doc should be thinking about juggling (if at all). So let me fly some scenarios by you, and I'm curious as to what you think. The details are all confabulated, but the essence of the stories have gone down in some form over the past few years.

For both the doc and the patient, I'm going to use the example of a hair appointment as a non-urgent but meaningful conflicting issue. It can be hard to schedule hair appointments, they take a while so they aren't that easy to reschedule, and someone else is inconvenienced (the stylist) by a change, and the consequence of delaying the appointment is meaningful (ya gotta live with ugly locks until you can get rescheduled). For the sake of my confabulation, you don't have to pay for a missed appointment, and it's hair, life goes on even with a bit of frizz (tell me about it).

For the sake of the uncontrollable, I'm going to use the car breaking down-- no one asks for this, it throws a miserable wrench in life, it's unanticipated, and if you can't get there, you can't get there. It could be "I was in the ER with chest pain," or "my husband locked the deadbolt and took the keys to work (and oh, we live on the 10th floor so I couldn't crawl out a window") but the broken car is the example of beyond someone's control to a reasonable degree.

Story #1) So patient calls and wants to come in emergently (asap). I look at my schedule and I have lunch time free, I finish at 3, and I have a hair appointment at 4. I offer 12 noon. Not good, patient has a hair appointment at 11:30, can I see her at 4? I can't (though I don't say that it's because I have a hair appointment). What's a shrink to do?

Story #2) Patient is having an emergency. Ah, a few days ago I came to see pt outside of regular office hours because pt was so clear it was an emergency and it couldn't wait until next available appointment. It was an emergency and I remained worried about pt. Pt canceled follow up appointment because his car broke down, but it was still an emergency, so could I meet him later in the day when relative would be home from her hair appointment and could bring patient? I quietly think: it's an emergency, relative knows it's an emergency. Can't relative cancel hair appointment? But it's been presented as this is something that would either be unacceptable to relative, or pt would be uncomfortable asking this of relative (and this I understand). Patient asks if I can move appointment to later in the day, a time I'm usually in the office. Oh, but I didn't have any appointments scheduled that particular day that late in the day, and I scheduled....you guessed it...a hair appointment! We looked at our schedules and couldn't come up with another time for many days and this is what we scheduled for.
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Do you want to know what I did? In the first scenario, I offered the patient a half appointment at the end of the day, and I was a late to my own "hair appointment," but every thing got done. I felt a little uneasy about it because-- The patient's other obligation actually felt a bit less conflicting then an actual hair appointment, and let's just say my own obligation got short-changed, and the issue at hand wasn't a psychiatric emergency.
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In the second scenario, I felt more conflicted. I know the patient wanted to come and he was out of control of the some of the scenario (? did he ask relative to skip hair appointment? Did he offer to drive another family member to work and borrow their car?). If this same patient had called and did not already have an appointment for that same day, and if my schedule was completely booked, I would have come back in the evening after my new doo to see him.

So what do you think?

Twitter Docs to Follow

Richard writes:

Given the popularity and prevalence of twitter, I put together a list of 50 different doctors on Twitter that you can follow to potentially get some insight on their medical lives. If you wouldn’t mind, could you share my list with your readers?

If you know of any other physicians that you follow on twitter, I'd love to add him/her to the list. Just leave a comment on the blog.


http://blog.onlinecollegeguru.com/health-care/50-doctors-to-follow-on-twitter/

Richard, Richard, Richard, oy~! Where is ShrinkRapRoy on your list? Where is ClinkShrink?
( I don't twitter or go tweet tweet very often so I won't care that I'm not on the list).

She's Coming Undone

I like to understand the things I own, to use them to their fullest, to know my options and pick and choose from an educated stance. I'm kind of all-or-nothing that way, and well, life in this technologic age has kind of undone me. I stopped watching television years ago. I remember in the days of old back when we walked barefoot through the snow the eleven miles each way to school when you turned on a television by walking up to it and turning a dial to go from Channel 2 to 5 to 7 to 11 to 13 and that was it. Now it takes 4 remotes to get my TV on (?maybe it's only 3-- there's the TV, the sound, the satellite) and I get 800 channels and can't figure out my choices and by the time I surf the landscape, and figure out what I want to watch (do I watch TV or TiVo?) and what I might like TiVo'd for later, well, it's time to crawl into the coffin.

Clink and Roy love it. They can spend hours comparing their IApps and who's bubblewrap is loudest and the joy that can be found from the Koi Pond application is just amazing. I have an iTouch-- it has on it:
500 some odd songs that I listen to at the gym. A handful of music videos and I'd like more but the iTunes store makes me very dizzy and nauseus. One TV show (an episode of scrubs) and a bunch of Apps, of which I use about 3: the NYTimes, iLose, doodlebuddy, flashlight (which I never use) and a game called Firestarter which I'm addicted to. I just added Pandora in the hopes of more music at the gym. We'll see. I'd like more TV shows, but how to choose? I was watching Wine Spectator video podcasts for a while, but I lost interest in wine.

To make it worse, I have an email addiction, so I limit the places I'll get internet. Home--and it ruins my life. The clinic (it's here, I didn't ask), the gym (so I can read the NYTimes online), but not my office, and not as a portable because oh, a blackberry or iPhone would do me in.

So I'm out with Camel and she's talking about how she loves her Kindle. I never wanted one. Now I want one. Oh, or do I want that iPad thingy....maybe I could take it to the gym and play my music and watch TV shows that I can't seem to negotiate, or UTubes or Podcasts, or Apps or my head, I swear, it's going to explode into a million pieces. Maybe I don't want it, maybe I just think I want it, but Clink says I do want it. Will this end my life without data plans? 1450 daytime minutes and unlimited texting, a windows desktop, an Apple laptop, an iTouch, a palm pilot, podcast mixers and mics, how much more can one shrink take?

Hospital computer won't let me add a graphic. Just as well.