Please Pass The Chocolate

This is for Victor, who sent us the link to a CNN article looking at mood and chocolate consumption: Chocolate and Depression Go Hand and Hand by Denise Mann. So here's the scoop, people eat more chocolate when they are depressed. Mann writes:

Although gorging on chocolate and sweets to beat the blues has become a cliché thanks to sitcoms and romantic comedies, there's been "little prior scientific literature linking chocolate and depression," says the lead author of the study, Dr. Beatrice Golomb, a professor of medicine at the University of California at San Diego School of Medicine. The study, she says, provides evidence to support "the popular perception that when people need a pick-me-up, they pick up chocolate."

It's unclear, however, whether depressed people eat more chocolate simply because they crave it, or whether chocolate consumption itself somehow contributes to a depressed mood.

In the study, Golomb and her colleagues surveyed more than 900 people about their weekly chocolate consumption and their overall diet. They also gauged the moods of the participants using a standard questionnaire used to screen for depression. (People who were taking antidepressants were excluded from the study.)

It's not really clear from the article if the article is talking about people with transient sadness or people with clinical depression, but if there's any link between chocolate and emotional states, then we're happy to link to it on Shrink Rap.

Victor: may your salsa win the contest this weekend. And I don't want to hurt your feelings but I've never been able to eat that chocolate bacon bar you gave me.

We're All Going To Die

I heard Irvin Yalom speak today. He's a psychiatrist/writer/ very famous shrink at Stanford, and he was at Johns Hopkins today to give the Jerome Frank lecture. The title of his talk was "Staring at The Sun: Overcoming the Terror of Death." It's also the title of his latest book. The auditorium was packed---no surprise here. When I heard Dr. Yalom was coming, maybe a month ago, I made a point to block off the time to be there-- I've never heard him speak and I was looking forward to this. Please let me share the experience with you.

Dr. Yalom is a gifted writer. He writes about his work in colorful and accessible ways, and he speaks about it this way as well. He lectures an audience of hundreds as though he is talking to a single friend. No notes, no hesitation, and he seems so at ease as he talks openly about work that is quite intimate. His specialties are group psychotherapy and existential psychotherapy, and he classifies the existential issues as death, isolation, freedom (as in freedom to make decisions and to steer the course of one's life, not political freedom), and meaning. "We are unfortunately meaning-seeking creatures heralded into a universe that has no meaning." Now he tells me!

Dr. Yalom started by talking about Dr. Jerome Frank (for whom the lecture is titled)--one of his mentors --and talked about a poignant visit with him near the end of Dr. Frank's life. Dr. Frank was also one of my psychotherapy supervisors, perhaps at a time in my training when I took such things for granted and had no true appreciation of what an amazing gift it was to be his student. Dr. Yalom talked about his memories, and I revisited my own.

Dr. Yalom talked about his own psychotherapy experiences: his three years in psychoanalysis in Baltimore "There was so much attention to the distant past and so little to the future and our death." Later in life, in California, he spent two years in therapy with Rollo May.

Death anxiety, Yalom contends, is an issue for many people--one patients won't necessarily bring up on their own, one they avoid if they sense the therapist is uncomfortable, one that, indeed, makes therapists uneasy as they, too, have their own death anxiety to face. Perhaps it's easier to avoid the topic; after all, there's nothing to do about it. We're all going to die. The therapist, he says, has a role in discussing death, and therapy can diminish the anxiety.

He talked a little about his work with cancer patients and how facing death can have a transforming effect; people get a better sense of priorities. "What a pity I had to wait until now to learn how to live," one dying patient told Dr. Yalom.

By far, the most interesting parts of the talk were when Yalom talked about specific examples of his own work with patients and the interactions that transpired. He talked about a patient--a psychotherapist--- who asked him about his own death anxiety (he responded) and who talked about his concerns about how Dr. Yalom might judge him. One nice thing about being Irvin Yalom is that you can get up in front of an audience of hundreds and talk openly about your work, boundary violations and all. He ended with the statement, "To become wise, you must listen to the wild dogs barking in your cellar." --a version of a quote by Nietzsche. I'm still thinking about that one.

It's been a while since I've heard a lecture like this. We've become so focused on psychiatry as the treatment of illnesses, of which drug at what dose, for how long, or which type of psychotherapy, and certainly we assume that what goes on in therapy includes talking about issues that having meaning to patients--including things that evoke anxiety, and the nuances of life that include meaning. We know we talk about these things behind closed doors--but we don't often talk about the process of such transactions.

My Three Shrinks Podcast 52: The Friendly Skies

In Dinah's post Fly Those Friendly Skies she talks about the new FAA policy regarding pilots on antidepressant medication. We found out something about pilot life span. Retired pilots live five years longer than their non-flying peers.

We talk about the New York Times article In Therapy: Cell Phones Ring True. The article discusses what therapists learn about their patients through their cell phone conversations and pictures.

Roy introduced us to the Lanny-yap blog, where we found a picture of Roy's dog, Eddie. This blog has a reference to a Scientific American article on anisomycin, an experimental medication that has been used in rats to wipe out fearful memories. Shades of Eternal Sunshine of the Spotless Mind (2004)!

Finally, we talk about a prospective study of 16,000 adults who started college and tried to guess which psychiatric diagnoses were most associated with failure to complete college. The full study can be found in the April edition of Psychiatric Services.

Once again, we talk about our upcoming book. We still need a title we can all agree on. Help us out by sending ideas to mythreeshrinksATgmail.com!

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This podcast is available oniTunes or as an RSS feed orFeedburner feed. You can also listen to or download the .mp3or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening

Send your questions and comments to: mythreeshrinksATgmailDOTcom

More on the Electronic Monster

We like to bicker about Electronic Medical Records here at Shrink Rap. They give Roy's life meaning. Clink and I are more ambivalent.

In An Unforeseen Complication of Electronic Medical Records, Dr. Paul Chen (NY Times, April 22nd) writes about trying to pay attention to the patient and the computer at the same time:

“EMRs are a phenomenal contribution to care,” said Dr. Ann S. O’Malley, lead author of the study and a senior researcher at the center. But there is often so much information available — some of which requires a direct and immediate response from the physician — that “some doctors liken the presence of EMR to having a 2-year-old in the exam room.”

As all parents can attest, while a 2-year-old can create chaos in any situation, a setting that is as delicately balanced as the clinical one runs the risk of falling into complete disarray. Doctors often must consider several issues simultaneously when seeing a single patient — all the potential diagnoses and possible treatments, the patient’s history and list of medications, any possible adverse effects or interactions, the limits of that patient’s health care coverage and numerous preventive health issues, to name just a few of those considerations. The addition of an electronic records system can push some doctors into what one EMR expert refers to as “cognitive overload.”

“The whole point of EMR is to simplify the process and to enhance and facilitate communication,” Dr. O’Malley said. “But in order for that to happen, EMR needs to be more user-friendly and more responsive to the clinical needs of patients and clinicians.”

Happy Blogiversary to Us!

Shrink Rap is Celebrating FOUR YEARS today!

Peeps, we gotta go out to eat! And no, Roy, you may not bring a sauerkraut banana cream pie.
-this is our 1,211th post-

She likes it! She likes it!

Do you remember the cereal commercial where everyone shoves a bowl of cereal at the dumb little brother to watch for his reaction? Mikey won't like it, he hates everything! But surprise, Mikey does like it!

We sent the final chapters of the draft of our book to our editor. So far, the process entails a bounce back, and sullen words like "this isn't working"...and then a lot of obsessing, a re-write, and finally we get to, "this is much better." It's become a bit of a joke--we build in time for her to hate it.

This Sunday, I stayed in my pajamas. I sat in front of a computer all day long. I didn't go out. I was ironing out the kinks in the last two chapters. Roy...well, I knew he was trying to write because he was commenting on old blog posts and he opened a new Facebook account. Why? I was ready to scream. I told Editor and ClinkShrink which day to reserve for Roy's funeral and to get their suits out. Roy didn't get it, he informed me he would be out of town that day and could go to a funeral on Sunday. Maybe he did get it.

Put the suits away. 12:30 AM and Roy's chapter was sent to our editor. Mine were sent a few hours earlier. Much quicker turnaround than usual: She likes them! I feel like those little kids when Mikey likes the healthy cereal.

I'm taking a moment now to just be happy.

Meet Prozac Pilot

Prozac Pilot!
Collin Hughes gave up his career as a pilot so he could get treatment for depression. He has a blog. He's now on the CNN home page. Watch his 'Coming out of the Hangar' video:



On CNN, Jeanne Meserve and Mike M. Ahlers write:
Meet Collin Hughes, a one-time rodeo cowboy turned jet pilot turned fledgling insurance agent, whose hope of returning to the sky has been reinvigorated by the new FAA policy. And who now hopes his story will embolden other pilots to address their depression.

Watch Me!

In the March issue of the Journal of Graduate Medical Education there is a paper entitled "How Residents View Their Clinical Supervision: A Reanalysis of Classic National Survey Data". This paper presents the results of a 1999 survey of 3,604 PGY 2 and PGY 3 residents. (The "PGY" refers to "post-graduate year", in other words how far along the physician is in her training after medical school.) The residents in this survey represented a random sample of 14% percent of all physicians in training, and almost two-thirds of the residents responded to the survey.

The good news is that the majority of the residents felt they had adequate supervision during their training.

Unfortunately, about a quarter of the residents reported that they had seen patients without adequate supervision at least once a week. Five percent said this occurred almost daily. Residents in opththalmology, neurology, neurosurgery and psychiatry were more likely to report inadequate supervision, while residents in pathology and dermatology were least likely to experience this.

Poorly supervised residents reported many other problems with their training programs, all of which could affect patient safety. Residents without adequate supervision also reported increased use of alcohol, significant weight change, or use of medications either to stay awake, to help them sleep, or to help them cope with the residency. They were also more likely to report higher ratings of self-assessed stress, sleep deprivation, total weekly work hours, and having worked while in an impaired condition. They were also more likely to report that they personally had been belittled and humiliated, or physically assaulted while working. In spite of all this, there was no correlation between sleep-related medical errors and being named in a malpractice suit.

Recently the Institute of Medicine issued a report with recommendations to reform graduate medical education. The report emphasized the connection between a healthy working (or training) environment and safe patient care. Surprisingly, medical organizations have not widely welcomed this. Certain specialty organizations are concerned that duty hour reform may deprive residents of valuable training experience and that the financial burden of duty hour reform will drive up the cost of health care. What this survey highlights is the fact that failure to adequately supervise residents and to provide humane working conditions creates a risk for the young physician as well as the patient.

My Three Shrinks Podcast 51: Vegan Gingerbread Cookies

For this podcast I brought some homemade vegan gingerbread cookies that I baked using a recipe from the Steph Davis blog. I'm also looking for a good sugar cookie recipe that doesn't use refined sugar or all-purpose flour. If you've got one, send it along.

We discuss my post Is it malpractice to lie? which involves a surgeon sued for malpractice for allegedly lying to a patient regarding his professional background. We wonder how much, if any, information physicians may some day be obliged to disclose to their patients prior to treatment.

There is a new type of research being done, called "in silica" research, in which people write computer programs to model behavior. We talked about computer models of suicide and how this can replicate suicide epidemics in real life. Roy is inspired to talk about a computer program that models how guys choose urinals in public restrooms, and how people stand in elevators.

We never got to the FAA policy discussion or the cell phones in therapy topic. That was saved for our next podcast.

Last but not least, Dinah takes her dog Max to the new office. Who knew that dogs could be terrified of elevators??

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This podcast is available oniTunes or as an RSS feed orFeedburner feed. You can also listen to or download the .mp3or the MPEG-4 file frommythreeshrinks.com.

Thank you for listening

Send your questions and comments to: mythreeshrinksATgmailDOTcom

Shopping Spree

CNN recently had a story entitled How physicians try to prevent 'doctor shopping', about states' efforts to control and prevent prescription drug abuse. While it's a good story, it's unfortunate that we only tend to talk about this issue after the overdose death of a celebrity. Here at Shrink Rap we've talked before about our concerns and challenges related to this issue in a series of blog posts and one podcast which we've collectively referred to as "the Benzo Wars".

The Shrink Rappers have seen both sides of the prescription drug abuse issue and so we have different opinions about it. Neither opinion is all right or all wrong, we just differ on the degree of the problem and to some degree how it should be handled. Our opinions are shaped by the patients we treat: Dinah has a private practice and (I'm guessing here) probably doesn't have many patients with active addictions or legal problems related to this. I work in prison, and nearly 80% of my patients are locked up for crimes related to substance abuse.

First, the things we agree about (and that the CNN story also addresses): we agree that doctors can't be detectives and that we aren't lie detectors. We have no special ability to figure out who is or isn't lying to us about their pain and anxiety or exaggerating problems to obtain medication. We agree that most doctors have certain 'red flags' that raise a concern about abuse. We agree (although Dinah thinks I don't believe this) that patients with real pain and panic disorder deserve care that is delivered in an empathic, sensitive fashion and that questioning or doubting these patients can cause serious problems with the doctor-patient relationship.

That was the easy part.

What the CNN article doesn't address is this: what do you do when you find out that your patient is, in fact, receiving multiple controlled substances from more than one doctor? The CNN article implies that whenever this happens it means the patient must be "doctor-shopping" and that there's a problem.

This situation is going to be more of a challenge for Dinah than it is for me, because in correctional facilities controlled substances are rarely prescribed. When they are ordered, they are dispensed in a tightly supervised manner and generally for a limited time. If an inmate is caught with pills in his cell---whether or not they were prescribed for him---you know the medication is not being used as prescribed. Easy enough.

But what about free society? What if the patient tells you, "I have chronic pain and I get medication from Dr. So-and-So." Truthfulness is a good indicator that the patient probably isn't out to snooker you. True drug addicts rarely give you an avenue to check up on them easily. Nevertheless, physiologic dependence can happen even in the absence of abuse. If the patient is coming to see you for anxiety, I probably still wouldn't choose a benzodiazepine as a first-choice medication because I wouldn't want to cause yet one more dependency issue. There are non-habit-forming alternatives and SSRI's have been shown to have anxiolytic effects.

But what if the patient comes to you already on a benzodiazepine? This is where the benzo war started on the podcast, and where Dinah and I may differ. In this case I think you have to consider what the goal of treatment is going to be and physicians are going to differ with regard to their comfort levels in this situation. Presumably the patient has been referred to you because the previous prescriber either was unable or unwilling to continue the prescription. Unless the prescriber was dead or retiring, to me this could indicate a clinician's concern about the patient's pattern of use and I'd be reluctant to merely continue the status quo. A reasonable treatment goal would be to build coping skills to the extent that either the patient would no longer need medication, or could function with a non-controlled alternative. As strange as it may sound coming from a psychiatrist who mainly does medication-management, I do believe that psychotherapy can help with this.

What if you find out that the patient actually is selling, trading or giving away your controlled substances?

Most free society docs don't find out about this until the patient gets arrested. But say the patient is released on bail---do you accept them back in treatment? Do you continue to prescribe for them? Or what if the other doctor is prescribing unusual combinations of meds, or meds in doses that would raise the eyebrows of even the most liberal psychiatrist? Do you assume the doctor is over-prescribing or do you assume the patient must really 'need' the medication?

It's a complicated situation, made more complicated by the fact that even non-controlled psychiatric medications have street value. And don't even get me started on legalized marijuana.

I'm not trying to start Benzo War Part II, but it's an issue that doctors struggle with. I await your thoughts.

Does EMDR Work?

This is actually Roy's post.

Eye Movement Desensitization and Reprocessing is a technique that is used to treat patients who have difficulties after a traumatic event or events. If you read the wikipedia link, it works. If you ask people, the jury remains out, and the technique has not found a place in mainstream psychiatry. That's not to say that there aren't psychiatrists who do this treatment or who refer patients for it, but most psychiatrists remain skeptical.

Roy was kind enough to do a little research and here's what he learned about the research on EMDR:

A Pubmed search for EMDR and limiting to Randomized Controlled Trials brings up 28 studies.

• 2008 study in BDD showed sig less negative body image in usual tx +EMDR vs usual tx (no placebo comparison).
• 2007 Swedish study in 33 kids 6-16yo with PTSD found sig lower sx. Again no placebo comparison.
• This 2008 Australian study is more interesting, splitting up the therapist's instruction from the actual eye movement behavior. The eye movement was the discriminating factor in producing lower sx of distress. No placebo.
• Van der Kolk's 2007 study of 88 people with PTSD randomly assigned to Prozac, EMDR or pill placebo was quite remarkable, with 75% of EMDR group having long-term relief vs 0% in Prozac group. Again, no placebo control for the eye movements. If we can do sham ECT and sham TMS, someone should be able to come up with sham EMDR.
• This one from Vancouver (from a co-resident of mine from Western Psych whom I would think to be a skeptic) broke out the different types of alternating stimulation, again finding a treatment effect.

Feel free to review the rest of them, but the data so far look promising. I did not see anything about harm from the treatment, so the risk/benefit analysis seems favorable, especially in an individual who has already completed unsuccessful trials of standard treatment.

What's your experience? Please tell us if you're a patient or a therapist who does this, or even if your friend had a good/bad experience with EMDR.

Fly Those Friendly Skies

We've talked before about whether having the diagnosis of a mental illness should prevent a person from pursuing certain careers. We've also mentioned that pilots, in particular, can not be on psychotropic medications. One concern is that a depressed pilot might not seek treatment because s/he fears losing her job. Is it better to have a pilot with untreated mental illness, or one on medication?

In The Wall Street Journal, Shirley S. Wang and Melanie Trottman write that the FAA has reconsidered this policy and will allow pilots to fly if they are being treated with Zoloft, Celexa, Lexapro, or Prozac. They write:

The new policy doesn't mean pilots who want to begin taking one of the medications can get in the cockpit right away. Before being granted a waiver by a physician certified by the FAA, a pilot must be considered "satisfactorily treated" for 12 months; in the meantime, he or she will be grounded.

For pilots who have been secretly taking antidepressants, the FAA is offering a grace period. The agency said it wouldn't take action against such pilots if they come forward within six months. However, pilots with a recent case of depression or who want to begin a new medication regimen will be subject to the one-year waiting period, according to FAA spokeswoman Alison Duquette. "We're really looking for stability," she said.

Grounded for 12 months? Seems like a long time. What do grounded pilots do? Do they get paid? Is this really destigmatization?