Saturday, March 27, 2010
In case you haven't heard, we've got ourselves health care reform.
What do you think?
Will this be a good thing for psychiatric patients?
Will this be a good thing for psychiatric docs (the shrinks among us?)
Personally, it's been so much commotion and so many pages, it's been way too much to follow (and no one asked my opinion anyway). I think I'm happy for movement, we've been stuck for so long with a system that just doesn't make sense. I'm told most people are happy with their health insurance. Are you?
Go for it, write in our comment section!
Friday, March 26, 2010
The title of this post comes from one of the questions in the Minnesota Multiphasic Personality Inventory, which I had to take when I applied to medical school. And I do like flowers. One of the things I like about the place where I work now is the fact that it's filled with plants---I don't know enough about horticulture to say what they are---but I think they are mother-in-law's tongue, ferns, philodendrons and other bushy green things. In front of the hospital there's a bed of tiger lillies and I can't wait for them to start blooming now that it's Spring.
Our hospital has a horticulture program. Patients who have worked their way up through the privilege level system and are safe enough to leave the ward are allowed to tend the many green plants lining the hallways and windows of the hospital. They do a terrific job and the place is beautiful and warm. I appreciate this a lot because I have a black thumb. When I walk into a nursery the plants scream and run for cover.
I think the patients appreciate the program because being able to participate is a sign of progress. Being able to gain some freedom and be responsible for another living thing gives a sense of independence and responsibility. It's also quite relaxing and peaceful to be surrounded by beauty.
Psychiatric hospitals and prisons have frequently used agriculture or horticulture for therapy and rehabilitation. I know of a maximum security prison where inmates with the highest privilege level are allowed to participate in a bonsai program, growing miniature trees.
Nineteenth century psychiatric hospitals relied upon hospital farms to provide for the needs of the patients. They grew their own food and milked their own dairy cows, which for some patients I'm sure was a source of self-sufficiency and pride. One former hospital farm, the Brattleboro Retreat Farm, still exists and is open to the public. In 2008 the New York Times published Tara Parker-Pope's article Better Mental Health, Down On The Farm in which commenters talked about their own experiences caring for animals during episodes of mental illness. One commenter talked about his horses as "a reason to go on" while depressed, because he had to feed and groom them even in bad weather.
While I didn't grow up on a farm, I did live in a rural community and many of my friends were farm kids. I still get teased for commenting on the progress of the corn crops as I drive through the country. I know farm life is not for everyone. The NYT article mentioned a Norwegian study that compared psychiatric patients treated with standard pharmacotherapy versus a group given standard therapy along with a "farm intervention", where they were asked to work with cows, sheep and horses for three hours a week over a 12-week period. By the end of that time the patients with farm experience had significantly higher self-efficacy and coping skills. Coincidentally, the farm group also had a higher dropout rate. The article didn't mention why the patients dropped out, but I can imagine why----cow pies are definitely not therapeutic.
Thursday, March 25, 2010
Monday, March 22, 2010
Saturday, March 20, 2010
Friday, March 19, 2010
In the New York Times this week we have a story entitled Animal Abuse as Clue to Additional Cruelties. In this article Ian Urbina discusses the problem of people who hoard animals and the connection between animal abuse and violence toward people.
The link between animal cruelty and antisocial behavior is well known and was first studied in the 1960's by a researcher at Washington University by the name of Lee Robins. Dr. Robins followed the outcomes of children referred to a local mental health center for conduct problems, and learned that about one third of them developed antisocial behavior as adults. This is where we get the current conduct disorder criteria for antisocial personality disorder found in DSM-IV: firesetting, theft, running away, truancy and animal cruelty.
States are passing laws to better identify and track people who hoard or abuse animals, with the idea that people who do this are also likely to be abusing or neglect humans in their households. The laws allow for sharing of information between people who investigate domestic violence or child abuse and people who investigate animal neglect cases. Some states are even passing laws to create registries of animal abusers.
Two parts of this story caught my attention: the registry issue and the idea that neglecting an animal becomes a predicate offense for other investigations. Here in Maryland we're big on registries. We have a sex offender registry and child abuse and neglect registry. We have a law requiring child welfare agencies to compare recent birth certificate information to the child abuse registry, to see if any known child abusers are having more kids. Now maybe we should also check to see if they're adopting pets.
The whole idea of registering and tracking people is a bit uncomfortable for me. Registries don't prevent crime but they can prevent people from getting jobs, buying homes and reintegrating into society after they've served their time. Being on a registry (or not being on one) is not truly reflective of the risk that person poses to society. A demented little old lady found with 200 cats in her basement could end up on the Internet, with the implication that she since she has neglected animals she also abuses children. Registries also don't seem to do much for preventing people from getting access to what makes people truly violent: guns and alcohol. Perhaps we should require liquor stores to check registries before any beer transaction. While we're at it, violence is associated with mental illness, untreated mood disorders and personality disorders. Maybe a registry of psychiatric patients?
Please. Enough. I doubt Dr. Robins ever expected this kind of outcome to her work. The purpose of studies like hers was to identify people at risk, for intervention and treatment, not for prosecution and public censure. I think we need to get back to that original idea.
Thursday, March 18, 2010
Wednesday, March 17, 2010
Tuesday, March 16, 2010
The author, Alex Mesoudi, used a computer model to study the effects of social learning and mass media influence on suicide clusters. He used a statistical method to see if suicides were clustered in time and space at an unexpectedly high frequency. This method is called an agent-based similiation, and is commonly used to model transmission of infectious disease. I'm not going to pretend to understand the statistics behind this! If you're curious you can read that part of the article.
He started by explaining the difference between point suicide clusters and mass clusters. Point clusters are suicides that are grouped together in time and space, while mass clusters are suicides that are grouped together in time, but are separated geographically. Suicide clusters have been thought to be due to social learning or mimicry, but it's also possible that they occur through homophiliy (the tendency for similar people to pool together in groups). Mass suicides are thought to be due to the influence of prestigious individuals (eg. celebrity suicide deaths) combined with coverage by the media. This leads to a one-to-many transmission model.
The computer model was run using three different assumptions: that suicides were totally random and unclustered, that clusters were due to social learning, and that clusters were due to homophily. He used different formulas to generate "suicides" under each model, and looked at the kind of clusters (spatiotemporal versus just temporal) that resulted.
What he found was that social learning caused spatiotemporal point clusters while homophilic clusters were more likely to be spacial rather than temporal. In order to understand this better, imagine the difference between teenage suicide epidemics versus correctional suicides. Teen suicides clusters happen among individuals who know each other, they happen in the same geographic area and within a short time frame of one another. These are the "social learning" clusters. Correctional suicides happen at a rate higher than in free society (in other words, they're geographically 'clustered' in a jail or prison), but are spread out over time. These are the homophilic suicides, in other words deaths by high risk people who happen to be grouped together. Based on this study, the correctional deaths are less likely to be due to social learning or mimicry.
Finally, the author studied the factors influencing mass suicide clusters: deaths that happen at the same time over a broad geographic area. These the kinds of suicides you see when a celebrity commits suicide. They are generally associated with a lot of media coverage. The computer model found that social learning played almost no role in these deaths.
It's a really complicated paper and I'm sure I didn't do it justice, but I thought it was pretty fascinating that someone could basically recreate the kind of suicide death patterns we see in the real world based on a theoretical mathematical framework. And I liked the term this author used for this kind of experiment: in silica. If in vivo experiments are done on animals or humans and in vitro experiments are done in test tubes or petri dishes, then "in silica" is a great term for computer model experiments.
And if none of this post made sense, hang on and I'll resurrect it in one of our podcasts.
Monday, March 15, 2010
So Dinah has gone off on vacation and left Roy and I in charge of the blog. Doesn't she know what a really really bad idea that is??
Saturday, March 13, 2010
Sarebear tells us she went to see a new psychiatrist and was surprised when the evaluation was begun by an Energy Healer and the psychiatrist joined at the end of the 90 minute evaluation. See her post, Psychiatry Bait and Switch.
So what's the standard here for psychiatric evaluations? Is there one?
Actually, yes, and here it is: Practice Guidelines for the Psychiatric Evaluation of Adults.
So let me tell you what my experience is of the standards, and we'll come back to the guidelines.
Who does the evaluation, in my experience, is determined in part by the setting. In every private practice setting I've seen, a psychiatrist does the evaluation--- who you schedule with is who you see. I believe that even in private settings, if you're having neuropsychological testing, you may get a more junior person who administers some of the tests. But in terms of psychiatric evaluations--- usually the shrink. Sarebare notes that psych evals are 90 minute events. I spend 120 minutes on them (and oh, I still run over, I gotta work on that)...but for many, many docs, they are 50 minute exams--- it's just logistically much easier on the scheduling, and if you're going to be seeing someone on an on-going basis, it's not that urgent that you get every piece of information on that first day (or you can send out detailed forms to collect info---see my post Please Print Legibly....) . In the Emergency Room of community hospitals, psychiatric evaluations are done by social workers who present the information to a psychiatrist who may or may not see the patient (granted, these are emergency issues only and do not constitute full psychiatric exams for the purpose of on-going treatment). On an in-patient unit, information may be gathered by many people---the nurse, the resident, the attending, the medical student, over and over again until the poor patient is exhausted!
In clinics, it's often the case that a social worker does an intake interview and then a psychiatrist sees the patient. The evaluation team may or may not be the treatment team; at the clinic where I work, one doctor does the evaluation and dictates a long (pages) note, but the patient is then assigned to another psychiatrist for on-going treatment. This was not my idea. In one clinic where I worked, the standard was to have a psychiatrist assigned to "coverage" for each hour and the covering doc was grabbed to do any needed psychiatric evaluations or see any patient who was due for a 90 day review (or med check)-- there was no consistency to care and bless the medical director who changed this and gave every doc a caseload and every patient a doc.
So back to the standards. Regarding the gathering of information, the Practice Guidelines I linked to say:
In many settings, it has become commonplace for the care of psychiatric patients to draw on the expertise of multidisciplinary teams. In the evaluation phase of care, other members of the clinical team (e.g., nurses, psychologists, occupational therapists, social workers, case managers, peer counselors, chaplains) may gather data or perform discipline-specific assessments. The psychiatrist responsible for the patient's care reviews and integrates these assessments into the psychiatric evaluation of the patient and works with other members of the multidisciplinary team in developing and implementing a plan of care.
Nothing at all, not a single word, about Energy Healers, but I'm not sure that a peer counselor would have more training, so I don't know what to say. Here in the Mid-Atlantic, we're not much for Energy Healers, though I did recently have my home sealed and insulated and my energy bills have been remarkably lower. Does this count? Sarebear, I hope it works out.
And now a word on Shrink Rap logistics. I am going on Vacation ! (am I happy: yes. have I begun to pack: no). Clink and Roy have not been blogging much lately, so I don't know if they will hold up the blog or not. I'm hoping Roy will take a look at proposed changes for DSM5 and write a blog post on these. Please bother him about this. And Clink has adopted podcast editing when she's not hanging off some precipice, so maybe she'll post another podcast....Dr. Barta was kind enough to stay and chat with us even when we stopped talking about telepsychiatry and brains. Finally, we had the odd realization this past week that while our book (Off the Couch, Behind the Couch, Under the Couch?) is due at the end of June, that version has to be finished with review, so the actual finished draft is due in April. Always a fun thing to learn as I'm headed off on vacation. Fortunately, we're in good shape for this, and the first 8 Chapters got a very enthusiastic review. So all good energy at Shrink Rap, but blogging may be a little slow. Please stick with us and check back often!
Thursday, March 11, 2010
Hypothetical situation (with a little ring of possibility)....
So a new patient shows up at my door, referred by a friend. The patient used to be in treatment with my friend, but the friend is moving to another state. The patient is sad, she will miss her old doctor who helped her so much, and while we hit it off just fine, it's clear that I can't fill my friend's shoes.
Now here is the thing I'm wondering about: the friend who used to treat the patient is my good friend, someone I talk to all the time --Are we thinking along the lines of a Camel? Perhaps, but I'll never tell. After the move, I'll still talk to her all the time, and I'll still see her socially, even if it means a bit of planning or trekking. Should I tell the patient? My initial thought is "yes" that this will be a connection, that I can relay regards and that the patient (and the doc) won't feel so cut off. But then I wonder if maybe it will be hard to know that I am seeing the old shrink when she can't, if somehow this might be frustrating?
I'd ask here, but clearly this is one where the answers may be very individual,--oh, but why not? Go for it!
Wednesday, March 10, 2010
Sometimes, especially on the podcasts, we get heated and go at it. Oh, sometimes on the blog, too. Among ourselves, we refer to these discussions as "The Benzo Wars" --the posts where we've argued about what role benzodiazepines and addictive medications have in psychiatry, and "Who Deserves Care" cause Clink thinks her patients need help more than mine (..if you see me walking around with bruises, you'll know it's me......)
So what else do Shrinks argue about? We've got a colorful history here. Took us decades to decided if homosexuality was a disorder (yes, maybe, no). Is psychosurgery with knitting needles good? Should our patients get special accommodations? What if I'm allergic to your support dog?
Ah, we're writing a chapter and I like the input you all give!
And please listen to our podcast. We're back...probably monthly for now, but weekly once we finish the book and they teach me how to edit them.
Sunday, March 07, 2010
|Find show notes with links at: http://mythreeshrinks.com. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom).|
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Thank you for listening.
Saturday, March 06, 2010
Paperdoll commented that ?she (?he-- do paperdolls have gender?) likes posts about "normal."
The quick answer is: No, you're not normal! Normal people don't call themselves "paper doll." Normal people also don't write blogs called "Shrink Rap" or post photos of their feet all over the internet.
I'm a psychiatrist and people ask me all the time "Is that normal?" or worse, "Am I normal?"
And we start with a semantic disconnect here: I equate "Normal" with "Booooring!" and would gladly wear a pin that says "Why Be Normal?" Like Why? What is normal? Why would anyone aspired to that. Normal is an IQ of 100, corn flakes for break fast and tuna fish for lunch (ok, I like tuna)..normal entails conforming to some exact mediocre standard. Why would you want to be Normal. Please don't call me normal (I think I don't have too worry too much here).
To my patients, however, "Am I normal?" doesn't mean Am I normal, it means "Please tell me I'm not crazy." You're not crazy. Okay, Paperdoll, I don't know you, and I don't know what crazy means to you, but there's probably a good shot you're not crazy. And I am definitely not crazy. Oh, yeah, I'm a psychiatrist and I'm not supposed to use the word crazy. Okay, you're normal.
So sometimes I'm told that I'm too normal to be a psychiatrist. Oh, all the Shrink Rappers---believe it or not--- kind of "look" normal....except for ClinkShrink who has started acting like Spiderman while she repels off steep cliffs. Apparently-- or so I'm told-- psychiatrists don't look normal.
Where am I going with this? And why? Is this kind of bloggy discourse normal?
Wednesday, March 03, 2010
Allan Frances chaired the APA task force that created DSM-IV. On Monday, he had an editorial in the Los Angeles Times called "It's Not Too Late to Save Normal."
Dr. Frances writes:
The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day -- despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.
The manual, prepared by the American Psychiatric Assn., is psychiatry's only official way of deciding who has a "mental disorder" and who is "normal." The quotes are necessary because this distinction is very hard to make at the fuzzy boundary between the two. If requirements for diagnosing a mental disorder are too stringent, some who need help will be left out; but if they are too loose, normal people will receive unnecessary, expensive and sometimes quite harmful treatment.Okay, I have a confession to make here: I don't keep a copy of the DSM in my office. I own an edition which I've opened a couple of times while writing our book. I don't care what the precise diagnostic criteria are: mostly I know them, but I'm left with the fact that if you wander into my office saying you're tormented and suffering or having trouble functioning, I'm going to treat you. And if I prescribe medications, it's mostly based on symptoms. Totally? No, because if there's history of mania (I know those symptoms) or any sense that the diagnosis might be bipolar disorder, I'm going to go pretty gently with the antidepressants, just because I've notice that people with tendencies towards mood instability (whether or not it meets criteria for full mania) do better if the antidepressants are kept to a minimum. I hear we over-diagnose, but I'm going to comment that absolutely no one has ever come to see me for simple, uncomplicated grief or a normal reaction to a stressor-- people just don't define this (and let's hope it stays that way) as a reason to run to a psychiatrist. And everyone's favorite diagnostic complaint: Shyness vs. Social Anxiety Disorder. 18 years of practice and how many patients have come with a chief complaint of isolated social anxiety? Zero. And how many patients in my practice carry the diagnosis of Social Anxiety Disorder? Zero. Over-diagnosis of mood and anxiety disorders in general? Of course-- maybe we're treating people who previously would have just suffered. Or maybe we're forced to assign a reimbursable diagnosis because V Codes (phase of life and relational disorders) can't be reimbursed. It all gets to be circular reasoning.
So who's placing bets on whether I purchase the DSM-V?
Tuesday, March 02, 2010
I'm talked out on the subject of whether or not psychiatric illnesses exist and whether or not psychiatric treatments work. I went to work today. I think I'll go again.
For the sake of completion, here's Louis Menand writing in The New Yorker, "Head Case." Click the link and read away.
Monday, March 01, 2010
Psychiatry's getting blasted this week: we don't know what we're doing, our diagnoses are not valid or reliable, our treatments no better than placebo and we maxed out in the 1960's with imipramine. Yesterday's NYTimes Magazine article on The Upside of Depression (see my post) implies that we're derailing evolution by treating what may be an adaptive condition, and The Wall Street Journal says Psychiatry Needs Therapy ! Edwarder Shorter writes:
Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications. Patients who seek psychiatric help today for mood disorders stand a good chance of being diagnosed with a disease that doesn't exist and treated with a medication little more effective than a placebo.
What's a shrink to do with this? Perhaps the diagnoses we make are wrong and the meds we use are ineffective, but at the end of the day, the patients seem to get better. Maybe it's my charm (hmmm, there's a thought) or the concurrent psychotherapy, or some other non-specific factor...maybe the cognitive dissonance that you have to believe that anything you're paying a small fortune for has to be working.
So do read Shorter's article and tell us what you think.