Friday, September 30, 2011

Guest Blogger Dr. J: The Well-Planned Unexpected Retirement

 Dr. J wrote an article for a shrinky publication about how she was carefully planning her retirement with a one-year lead time.  Things did not go quite as expected and she wrote a sequel detailing all the distress of her well-laid plan going totally awry.  Dr. J kindly agreed to let Shrink Rap re-run the second segment of her story.
       *                *               *               * 
I find it an ironic and even embarrassing fact that my prior article was mailed out on the very same day on which, instead, I abruptly announced my permanent retirement . I retired five months earlier than my patients and I had expected, and much earlier if you count the many prior absences that occurred in the Fall.  After a full year of working on terminations, my hopes and plans for that year, my high clinical expectations. This is what really happened.
This is definitely an odd little autobiographical piece following my own recent medical history, which, unfortunately, is necessary to understand the quality and prematurity of my retirement, and the consequent effects on my patients and me. Just before Labor Day, I suffered a surprise episode of severe atrial fibrillation, caused by a ruptured mitral valve chorda.  I was out for most of a week for a fast work-up, and then out again just before the planned but postponed  surgery for over a week in September, in the hospital for a near-sepsis severe abscess at the coronary angiogram site. That was followed by being in and out for pre-surgery-related reasons. I was away from early October through mid-November for the successful mitral valve repair, but it was complicated by a horrifying post-op delirium/reactive paranoid psychosis.
I learned, in a personal way, a lot from that all-too-common post-op experience- things that patients had told me about psychosis in so many ways in the days when I treated psychotic people. These words are carefully and precisely chosen by me: By being told that I was wrong about my memories of what happened, what I had perceived to be absolutely true, I was relinquishing memory ownership, and that is a very, very bad thing. It costs, deeply. It shakes you to your bones, especially since nothing in my mind has yet changed about those memories of mine feeling correct. Post-op delirium or psychosis occurs up to 50% of the time after major invasive surgery, especially cardiac, and yet it usually goes undetected unless it is the noisy kind, as mine was not. It very often evolves into PTSD, as mine did. It became part of the weave of my early retirement.   
In early September, to quote one very perceptive soul, I had been “la-dee-da” about my impending leave for open heart surgery. Such serious crises were in some patients’ lives, dying loved ones, children plunging into mental illness, marriages falling apart, so much  demanding direct attention.  My surgery was mostly a lousy time for me to be disappearing on them, though all wished me well and expressed concern. My planned retirement was also a lousy time to be disappearing, as it was beginning to feel closer now, and this was a clear deletion of time and a harbinger. The leave coverage I arranged was of little comfort. At that point I didn’t feel my work was out of whack, my denial intact and working for me. An impending long leave was all new stuff to me, never having been away for more than a two- or three-week vacation, never more than two days out for illness in all these years. It seemed that my surgical leave could be a trial termination, leading to more productive work afterwards about inevitable change and loss. However, with each leave before surgery, I felt less sure of my tidy wish. 
Instead, when I came home to bed four days after heart surgery, no la-dee-da affair at all, with too little energy to do more than lie there, an effort to produce sound bites, PTSD came roaring in behind the untreated post-op paranoia. In spite of depletion of all energy, my body had not lost the capacity to experience terror, day and night. I made a truly desperate phone call to a Baltimore psychiatrist whom all of us here know and deeply admire. He could hear all he needed to know in my voice. The kind man arrived that same evening, came to where I was bed-bound and listened patiently.  He returned until I was able to drive to his office, and I’ve been seeing him since. He has been, as I had experienced in my analysis with a very special woman, useful beyond description. I underline this important revelation because of that despicable New York Times front page article of 3/6/2011 by Gardiner Harris, the one about psychiatrists giving up doing therapy. It deeply offended me, saddened me, and left me feeling that maybe it’s a good time to “get out." It so minimized the incredible need for psychiatrists to remain extremely capable, compassionate and wise psychotherapists, because I have also needed his medical expertise.
Sometime in early November, overlapping cardiac recovery, I developed inexplicable atypical, severe bilateral leg pain at night, resulting in terrible insomnia with sleep-deprivation and/or grogginess from meds meant to alleviate those. I had increasing difficulty with concentration, memory, and attention as the psychological sequelae of both sleep deprivation and PTSD, which I definitely had. Nonetheless, I soldiered on and then returned to practice. I was limping along as a therapist, occasionally looking puzzled when there was nothing puzzling. At times, I said things that were misworded or syntactically upside-down, without enough awareness except for the consequent expressions on my patients’ faces. I looked exhausted and was. I was beginning to scare patients about my health, I think. They were worried now, and some would say so. One woman opined that I had underestimated what this surgery would take out of me. (That was certainly true.)  When asked, when there was a clear need to explain my inexplicable degree of exhaustion, I did, and one patient suggested Ambien, which of course has a humorous side to it. I didn’t know the cause of my pain-generated insomnia, so I couldn’t give my patients very helpful answers. In total, given all the interruptions, I was at work for about eight or nine scattered days after September 1st  until January 1st.

I too was seriously worried, eventually becoming flat-out desperate, since none of the specialists that I was seeing urgently,  knew what was wrong to cause such intolerable leg pain at night. Though never my very kind and talented choreographing internist (to whom I am forever indebted) nor my psychiatrist, some specialists diagnosed psychogenicity. Two very bright others worried about a possible paraneoplastic syndrome. Patients were aghast that I’d cancel again and again for more testing, with less and less time left for our treatment. Some were getting almost frantic about these appointments of mine, and most had a hopeful suggestion, a theory, a favorite doctor. Those who really needed to be seen regularly, I tried hard to persuade them to transfer to new therapists at that time, with limited success.
I realized things were subtly turning upside down in my office. Those few patients I saw during those remaining days were trying to help me now.  Therapy was about anticipated loss, no doubt including loss of control over my help and presence. My desperate effort was to be the kind of therapist I’d “always” been, wanting so much to go out with my vision of helpfulness and my self-respect intact, with a sense that my thirty-five year career had ended well. I wanted to make it to the finish line that I had chosen, with the final work I had hoped for with each patient. There were so few actual patient sessions that this was mostly wishing, not occurring, in my office, but my head was swirling with how to do it. The Thanksgiving holidays fouled up my office scheduling again. 
Then, having had pain-related insomnia all night for days, with so many patients still unseen or seen only once since August or September because of all my leaves, I fell asleep on two longstanding patients. I apologized profoundly and explained. I knew then, really knew, that I must simply stop.
I went straight home and called a very dear friend and colleague who came over to help me make a plan, advised me with her ever-present wisdom. Afterwards I called every patient to say that I was taking yet another leave until mid-January, unable to say to them, or definitively to myself yet, that this would be a final leave, and certainly unwilling to do so right before the holidays. But I did know, and couldn’t stand to feel it all at once. My explanation to my patients was uncharacteristically vague because in fact my malady was. Sometimes I had to communicate my “leave” on answering machines, giving my news and saying I’d call back, a brutality of modern electronic life. I always left my home phone and home email for them to contact me. I worked on a list of therapists whom I thought would be good matches, leaving preliminary queries for those psychiatrists and non-psychiatrist therapists, all of whom responded so generously, giving of their tight practice time, such gifts
With no progress in diagnosis and treatment for my unusual and intense leg pain, with so many tests and consultations ahead, with my insomnia unremitted, I faced calling every patient to say that there had been too many leaves, so that in fact I was retiring early, as of now. That was an indescribably horrible week in my life. Most of them had wondered if that was coming, so not a great surprise, but instead they were shaken, very disappointed, wondered if I was dying of something- no matter how I tried not to be alarming, up against this abrupt loss due to an unknown, without any control at all over the matter. I gave each my specific referral. I invited each patient to think about whether he/she would like to come by my home at some future point for a brief good-bye in person. I moved my office furniture out. Only in mid-March, with the help of my psychiatrist’s medical acumen, was my pain diagnosed as originating from an unusual configuration of lower back spinal disease sites, with fairly extensive lumbosacral surgery. Relief came in between diagnosis and surgery with those lovely steroid injections in the spine and through the foraminal canals by a menschy ace needler. After surgery, I just might have made it back to work by the original retirement week.   
Such truly chaotic endings for my patients, and retirement for me, after knowing a few of my patients for almost twenty-five years. I had never imagined becoming ill in a way that made for such a scheduling mess, mystery, and ultimately trouble working. It grieved me so much that I kept plugging along until the worst of all insults, falling asleep with those two patients, patients who were sharing their secrets and their vulnerabilities. I have always been merciless in my mind when patients have told me about former therapists who did this with them. I have seen the cost of that rejection to them. I am deeply fortunate that these two were so healthy as to understand what this was about, and that I had long track records with them. But who knows if that day will be without any consequence to them, last sessions that they were? Both chose to come say good-byes at my home and both expressed gratitude for our work. They seemed free of such consequences, but the psyche runs so deep and their need to protect me so probable.
When I had invited each one to come say good-bye if they so chose, I made it clear that either way was fine, something to think about. Every one wanted to, though some wanted to postpone it until they didn’t feel so raw, until I was better, until the flowers were up, until they felt their new therapist could be a cushion, and so forth. Since then virtually all contacted me, patients whom I was actively seeing when I retired and many who only very occasionally still came in from the past, who asked to come for these brief visits. What I hadn’t anticipated was how powerful these meetings would be, then ending when we both felt it was a natural moment, when we both could tell we’d said what had been important to say, when we both stood up together. Inevitably each recently seen patient commented on their relief that I looked so much better, i.e. that I didn’t look like I was at death’s door, as I had.  Each had their individual things that they wanted to say, realized that they’d needed to say, and sometimes saved questions too. These were intense, condensed opportunities to put their questions and thoughts right into context, to give them historical meaning, because of our years of relationship. I hope and believe that many left with something useful to think about.                                                                                                                           
I saw how very brave these fine people are when they chose to come here and handle the finality of these good-byes with such focus, direction, and emotional candor in a different setting. They wanted to tell me how far they’ve come, what they had accomplished, what they are still working on and probably always will be. Most told me that they had felt cared about and could hear my “helpful voice” internally. As they said that, they patted their chests, not their heads, every one of them. They wanted to thank me, and I certainly wanted to thank them too, hand automatically going to my heart too, for the privilege of watching their growth, their hard work, for sharing themselves with me and more than that. They gave me the chance to say good-bye, some aware that they were doing that for me too.
It certainly has been useful for me to see them, a way to offer small amends for such a desperately awful ending, to be reassured myself, and for me to have my opportunity to grieve after each visit. I am infinitely grateful to all of them for their enormous patience , their genuine good wishes, their willingness to try new therapists and usually connect well with them, their courage, and these not-so-easy good-byes in person. They have been heroic. My gratitude for my surgeries by talented surgeons had been overshadowed by the black dust of this forced retirement. Thanks to my former patients and my own psychotherapy, I am now able to feel fortunate about that and my career again, in spite of the robbery of my tailored retirement plan and my lost absolute insistence on control over that. We do know we don’t have that, then we learn that we don’t have that, and then we learn that, and then learn that again, and then I suppose one day we may get that.
Reprinted from The Maryland Psychiatrist.

Thursday, September 29, 2011

This Little Piggy

I'm dedicating this post to Roy because I wouldn't be in the least bit surprised if one day he announces he's raising pigs.

In yesterday's Baltimore Sun there was an article about two pigs who were living around an office park.  What's this got to do with psychiatry?  Oh, my, I will leave that one to you.  Luke Broadwater writes:

The first pig, a female, was captured last week with nets, animal control officials said. Both pigs were taken into custody in the 600 block of Hammonds Ferry Road.
Karen Gower, manager at the Red Wing Shoes store near where the pigs were apprehended, said her employees are going to miss the animals, which they used to watch regularly. One of her employees, she said, was feeding them.

"We understand they had to take them, but we're kind of sad to see them go," she said. "They would lay there stretched out like a dog under a tree for hours."

Animal Control Officer Glenn Johnson and Jim Bennett of the Department of Natural Resources were praised by officials Wednesday for pulling off the capture of the second pig, which involved the use of tranquilizers. Officers were concerned about the pig's safety, they said.

Wednesday, September 28, 2011

Would You Like Prozac With Your Latte?

The Guardian recently published this story about a longitudinal Harvard study of 51,000 female coffee drinkers followed over ten years. They found that there was a 20% lower risk of clinical depression in the women who drank four or more cups of coffee a day compared to non-drinkers. This is consistent with a previous study of 86,000 female nurses followed over ten years, where they found that the relative risk of suicide was reduced even for moderate to low coffee drinkers, defined as drinking two or three cups per day.

This is good news for me since I usually start my day with a half a pot before I get to work. (Yes, that much, really. No wonder Dinah sent me a link to this story and said, "You've gotta blog about this.")

The trick is, there may be a ceiling effect to all this: once you get to eight or more cups a day this risk of suicide starts to increase again according to one study.

Somewhat gratuitously, the Guardian article threw in reference to our "druggy society" and faulted the researchers for not considering other factors like social supports, involvement in religious groups or community activities, and even whether the women were drinking coffee alone or with friends:

"As the scientists will also tell you, neurotransmitters respond to everything: hugs, kisses, conversation, books, pictures, gardening, hunger, worry, rows, war – all raise or lower chemical levels."
Ah yes, clinical depression and suicide must be the result of not getting enough hugs or the fact that you haven't taken up gardening. Cringe-worthy health reporting, at its best. The reporter concludes:

"...supposedly scientific comments of this sort serve little purpose except to coax women into a state the doctors can then medicate."
Amazing. A simple study about caffeine and depression has somehow been morphed into another nefarous plot by evil Dr. Pillshrink.

Tuesday, September 27, 2011

Physician and Social Media Survey

On the American Medical News site, here's an interesting article about a recent study about social media use by physicians. According to a survey by QuantiaMD, nearly 90% of physicians use social media, much more than the general public. Most social media use---about 67%---is for personal reasons. A third of physicians reported getting at least one Facebook friend request from a patient, but most of these requests are turned down. For me the most interesting thing was that only 8% of physicians reported using a blog for professional reasons. That seemed low to me.

Not too much more to add, just thought I'd put up a link to the article.

Monday, September 26, 2011

The Psychotropic Media Wars

 Just in case you haven't had enough of people ranting about the efficacy (or not) of psychotopic medications in the popular media, I thought I'd refer you over to an article by Dr. Harold Koplewicz on The Huffington Post.  Here's a quote:

Good studies for psychiatric treatments are desperately needed. In the meantime, we have patients, in our case children and adolescents, who desperately need help. These children may be out of control, overwhelmed by anxiety, dangerously aggressive, disorganized in their communication, floundering in school. We need to help them. Medications, often along with behavioral therapy, can have a transformative effect. If they don't help, we are not forced to continue using them. We would like to see objective research catch up with the clinical realities but can't wait until that happens. Furthermore, falling back on pure non-pharmacological treatment is not the better alternative, since these treatments have rarely undergone objective evaluation.

As to the issue of psychoactive drugs actually harming patients by altering their brain chemistry over the long term, which Angell posits, here too data is lacking. It makes no sense to forego present benefit because of undemonstrated future harms. We try to weigh the risks of psychoactive drug treatment against the risks of forgoing treatment. That risk often includes academic failure, dropping out of school, substance abuse and even suicide. Unfortunately, the risks of avoiding demonstrated useful treatments are not something critics, like Angell, consider.

Sunday, September 25, 2011

What Medicare Cuts May Mean For Patients Who See Psychiatrists

Over on Shrink Rap News, Roy wrote a post about proposed Medicare cuts.  He continued the conversation here on Shrink Rap.  

I want to expand on the discussion in what I hope will be easy-to-understand terms.  Why would anyone who is not a doctor even care what Medicare reimburses their docs?  Let me tell you why you might care.

Doctors all have one of four designated categories within the Medicare system:
1) The doc participates and accepts Medicare assignment.  The fee for the service is set by Medicare, the patient makes a co-pay and the doctor bills Medicare and gets the rest of the fee from Medicare.
2) The doctor is "non-participating" --which is a deceptive term, because non-participating docs are within the Medicare system.  The fee for the service is set by Medicare and is typically 5% less then the fee for participating docs, but the patient pays the Medicare fee in full to the doctor, the doctor files a claim with Medicare, and Medicare reimburses the patient for a portion of the fee. 
3) The doctor has formally opted-out.  In this case, the doctor charges the same fee that every other patient is charged, the patient pays the doctor in full.  No forms are filed to Medicare and the patient receives no reimbursement at all.  A doctor who opts in one setting is opted out in all settings, so one can't opt out in private practice and also work in a clinic where Medicare is accepted. 
4) The doctor never files anything with Medicare.  He can not see Medicare patients at all, ever, in any setting.  Perhaps he can see patients for free(?), but no money can change hands and no forms get filed.  This is not the usual.

The current proposal is for a 30% cut in provider fees for 2012.  Oh, we dance this dance every year.  But this year, the thinking is that it may stick.  As is stands now, the current Medicare fee for a non-participating provider in the area where we live, for a 50 minute psychotherapy session, with medication management, in a non-facility (meaning, for example, a private practice that is not hospital-based) is $120.96.  This fee is notably lower than going community rates, and because of this, many psychiatrists who practice psychotherapy have opted out: they can charge what they'd like and they don't have to deal with the hassles of filing any paperwork.  Oh, but it's not just psychiatrists, some internists have opted out of Medicare.  It means that when you hit 65, either you pay your doctor out-of-pocket, or you change doctors.

Currently, it's hard for patients to find psychiatrists who participate with Medicare, and those who do often limit new Medicare patients. A doctor can come highly recommended, and you may be a multi-millionaire, but that doesn't matter, because once a doctor is in Medicare as either participating or non-participating, the fee is set by Medicare and being rich doesn't buy you in, because all Medicare patients pay the same fee. 

If the fee drops so that an hour of work is reimbursed at $84.67, a 30% decrease, more psychiatrists will opt out.  From the doctor's point of view, they kind of win: if they can hold on to a big enough patient base, they can charge their usual (generally higher) fees and they don't have to hassle with claims.  From Medicare's perspective, they definitely win: patients are forced to get care outside the system and they reimburse nothing.  It's not like going out-of-network with your private insurance where they will still pay for services, perhaps at a lower rate or with a higher deductible, but they do compensate for a chunk of the care.  Those doctors who remain in the system are those who can make it work for them--- they see patients for Pharmacologic Management with a code that does not have a time requirement and cram as many patients in as fast as they can see them.  But as SteveMD has pointed out in his comment, when fees drop by 30%, even the workhorse psychiatrists who can go at an exhausting pace of 4-5 patients per hour will be making much less money to provide one-size-fits-all 10 minutes-with-a-shrink care. 

From the patient's point of view: they lose.  Suddenly their doctor doesn't accept Medicare.  They now get hit with a much higher fee and they get no insurance reimbursement.  This is why you should care.
On a lighter note, the photo above is a picture of Oreo, a very sweet Havenese poochie we befriended during our book signing at the Baltimore Book Festival today.  I put a photo of us up on our Facebook more illustration of Roy ragging on me.  Please do visit our FB page at Shrink Rap Book and by all means, "Like" us!

Saturday, September 24, 2011

Medicare: Access to Mental Health Care in Danger

In many states, Medicare fees are at the bottom of the barrel, prompting physicians and other health care providers to stop accepting new patients or even to opt out of Medicare completely. A recent proposal from MedPAC (Medicare Payment Advisory Commission, which makes recommendations to Congress) would further reduce rates by up to 38% over the next 10 years.

I wrote an article yesterday in Clinical Psychiatry News explaining this critical danger to the health care safety net for seniors, baby boomers, and people on disability.

I think Medicare needs to reinvent its game by moving away from per-visit payments -- which reward volumes -- toward payments based on severity-adjusted episodes of care combined with quality and outcomes multipliers -- which rewards quality and efficiency.

By re-inventing the way Medicare pays all providers, not by quantity but by quality and efficiency, it has a chance to bend the cost curve without making it harder for beneficiaries to find a doctor who will accept Medicare. Medicare enrollees deserve to be treated better. If Congress messes this up, there will be hell to pay at the ballot box.
         Dinah added a post explaining what this might mean for patients at :

Moving Right Along Now

Sent to us from TigerMom and Jay at Two Women Blogging-- which is oddly enough a blog by three women (all that education and they can't count???-- and shamelessly stolen off BoingBoing

Nails painted like anti-depressants

Erin Simon had NYC's Marie Nails In Soho paint her nails like a variety of anti-depressants! (Thanks, Heather Sparks!)

david pescovitz

Comments for this page are closed.

Showing 11 comments

  • Why do i have the sudden urge to play Dr. Mario?
  • UnnecessaryUmlaut 09/16/2011 12:05 PM
    I don't think the white pinky nail is for Zoloft.
  • HenryPootel 09/16/2011 12:06 PM
    You know this could be an interesting placebo.  Just suck on the finger that's got the meds you need. Maybe put Viagra on the ring finger.
  • I think they're suppositories....
  • Seems symbolic since some people chew their nails when anxious or depressed.
  • facetedjewel 09/16/2011 12:25 PM
    Not being able to grow your own long, strong nails and feeling you have to wear fake ones *is* depressing. Symbolic of both cause and remedy.
  • Private Private 09/16/2011 01:28 PM
    I think I know why she's obsessed with anti-depressants. With nails that long, she'd have a hard time, uh, making the most of her natural dopamine highs, if you know what I mean. Wink wink, nudge nudge. Ouch.
  • I think this lady is depressed because of the way her hands look. Chicken, egg?
  • i suppose this is supposed to be "cute" or "wacky," but i find it highly offensive.  sorry.  there's nothing delightful about having one's quality of life (or some semblance of going through the motions of life, anyway) dependant on those horrible pills.
  • I don't know.  It takes a quite a few horrible pills to make me into a functioning member of society and I've made earrings out of most of them.  Sometimes it's better to laugh than cry.
  • You go Jamie Sue.... i don't know why hater's even bother to comment.... it's entertainment... nothing more, nothing less. for anyone to feel "offended" is their issue. Maybe they need to check out the pill selection on her left hand middle finger....... # yaknowhatimean

Thursday, September 22, 2011

Transference to the Blog, Revisited

Early on in Shrink Rap life, I wrote a post called Transference to the Blog.  A bit tongue-in-cheek but it was inspired by the idea that readers seemed to have their own feelings and internal relationships with Shrink Rap,  just as we had with them --so Counter-transference emanating from the blog was also addressed.   As was transference to the duck.

Over the years, the feelings and tone in the comment section of Shrink Rap has varied quite a bit.  At times it's warm and fuzzy with people writing in to tell their own stories-- good and bad-- and readers offering one and other support.  At other times, it's been rather hostile with reader writing in to express their venom toward psychiatry and to criticize other commenters who say they have benefited from treatment.  From my perspective, I thought things had calmed down, at least a bit, but we've gotten several communications from readers complaining they feel attacked if they make comments.  I worry that our continued commenter-constituent base of those who criticize the field has served to silence those who might like to have a voice.  Even my co-bloggers seem to have lost interest in engaging in these conversations.

Some of the commenters have asked why people return to make the same points over and over.  What interest is there in this drum beat of reiteration after reiteration of why psychiatry is bad.  I've wondered the same thing, and wondered why they don't form their own blog!  If you're a Republican, don't you frequent Republican blogs?  Why hang out and hound the Democrats?  Do Jewish people standout side Catholic Churches to make the point that the Catholics are wrong in their beliefs?   Which brings me to the subject of Transference to the Blog.  Obviously, I can't speak to the motivations of people I don't know, but I am allowed to speculate in my head, and I can't help but assume that those who visit with a repeated agenda that opposes the spirit of by-psychiatrists-for-psychiatrists (and anyone else who might enjoy the ride), do so because they've had a bad experience and Shrink Rap might serve the purpose of being a flame to the metaphorical moth.  It feels like a compulsion to revisit the site of a trauma in the hopes of mastering it.  Sorry if this is too shrinky for you, but oh, hey, I'm a psychiatrist and we do sometimes think this way.

When people make the same adversarial comments over and over,  it gets old and it stifles new ideas and new discussions.

If you believe that psychiatrists wrong patients by inflicting diagnoses on them, that it's wrong to take medications for psychiatric problems or psychic distress, that psychiatrists have evil motives, that psychiatric disorders do not exist, that psychiatric hospitals inflict damage, that involuntary hospitalization is never, ever, warranted no matter how sick or how dangerous someone is, or that psychiatry is about inflicting punishment/being coercive & controlling,  and not about healing or treatment, then please know we have heard you.  You're welcome to your views, but the writers of Shrink Rap don't agree that these are over-riding themes in psychiatry as a whole, and expressing the same opinion and rationale for the 27th time is not going to change this.  On the other hand, it does appear to offend many people who might like the opportunity to comment, express themselves without a barrage of insults, and garner either support or similar stories in a welcoming environment.

This may be read as Don't Criticize Psychiatry.  Read it as you wish.  I don't think we've ever steered readers away from an honest look at the issues, or that we defend every aspect of our work as done by all of our colleagues.  Our book is about psychiatry with the good and the bad, and we mostly discuss it in positive terms with the hope that this will set the standard :  Hey, none of the docs in Shrink Rap are prescribing medications after 10 minute evaluations, they all listen to their patients and have thoughtful discussions--  maybe that's what I should expect.  

If you've made your point, it's been made.  If you have a new point and it critiques psychiatry in a new way, please say it in a manner that is respectful of those who may be struggling.

Tuesday, September 20, 2011

Come Meet the Shrink Rappers!

Need something to do on Sunday before the Ravens game?  Need a good book to read?  Want to meet your favorite blogging Shrinks?  Come visit the Shrink Rappers on Sunday, September 25th at 1PM in the Peabody Library.  For more details see The Baltimore Book Festival Website.

Monday, September 19, 2011

Is This Depression?

Over on KevinMD, an anonymous doctor has post up called the Absence of Joy about his own problems with depression.  He writes:

For ten years I fought against the feeling that for long periods of time I was abnormally unimpressionable.  Not all the time, but certainly for moments. I was neither incredibly happy nor depressingly sad.  I put all this down to the stresses of making ends meet by moonlighting in ER’s, working impossible hours, studying for interminable exams, followed by the stresses of looming loan repayments, cash flow crises, parenting and marriage demands as my practice struggled to find its feet.

During moments of reflection I would question my condition, briefly consider depression as a factor, and then disregard it completely.  I was sleeping well.  I was not miserable.  Just stressed, like many of my colleagues.  Burn out was the diagnosis I chose for myself, and there seemed to be no easy option to deal with that.

But as the joy withdrew from my life, I was unable to identify the cause within.  I looked for other causes.  If the reason was not internal, it had to be external.  I found subtle fault with everyone around me, my wife, my kids, my career, my patients, my staff.  I considered changing my situation, leaving all of these, building another life, because this one did not appear to make me happy.
My wife saved me from myself.  Some ultimatums later, I was presented with a diagnosis of subclinical depression and began taking an SSRI.

He goes on to talk about how much better he feels and how much less labile his moods are.  He mentions things rolling off him like they'd roll off a duck's back, and of course we Shrink Rappers are big into ducks. 

So why am I writing about this blog post?  I think because I wasn't so sure I would have offered this patient medications.  Of course it's only a snapshot, and sometimes a recounting of symptoms on paper does not match the distress that a live person can convey, but the writer does not describe clinical major depression, what we think of as an illness.  He does a great job of describing existential angst, and makes no mention of whether he's had psychotherapy.  Perhaps he describes dysthymia (a low grade chronic depression that depletes the patient) but I wasn't totally sure.  I almost had the sense while reading that he's taking a happy pill that moves him to complacency. But the writer describes a huge relief, satisfaction with his outcome, and who am I to second guess? 

Just thought it might make for some good conversation here on Shrink Rap.  Do check out the whole post over on KevinMD by clicking here.

Thursday, September 15, 2011

No More Xanax

I'm posting this because Roy fell asleep at the wheel and missed the Xanax article on the front page of yesterday's  New York Times.  In "Abuse of Xanax Leads a Clinic to Halt Supply,"  Abby Goodnough writes about a clinic where they've stopped prescribing Xanax because to many people are abusing it.  Goodnough writes:

“It is such a drain on resources,” said Ms. Mink, whose employer, Seven Counties Services, serves some 30,000 patients in Louisville and the surrounding region. “You’re funneling a great deal of your energy into pacifying, educating, bumping heads with people over Xanax.”
Because of the clamor for the drug, and concern over the striking number of overdoses involving Xanax here and across the country, Seven Counties took an unusual step — its doctors stopped writing new prescriptions for Xanax and its generic version, alprazolam, in April and plan to wean patients off it completely by year’s end.

If you want to know how the Shrink Rappers feel about Xanax, do read Roy's post on Why Docs Don't like Xanax (Some of Us).  It's been our all-time most popular post.  

So I was a little (not a lot) surprised that this was "news."  I've worked in four public clinics-- I've never seen a prescription written for Xanax, and for the most part, the clinics where I've worked have had a sort of non-stated ban on prescribing controlled substances.  It's not that benzodiepines and stimulants are never helpful, but in the clinics, the issues concerning abuse, and the drain on the system gets to be very hard, plus we worry that the harm these medicines can do will be worse than the problems they 'cure.'   It's very rare that I've written for controlled substances, and I've never written for Xanax in a clinic, or seen a chart from another patient where Xanax was prescribed. I'd be shocked by the article, but during the two weeks I was in Louisiana after Katrina, I did see many patients who had been on high doses of long-standing Xanax that were prescribed by docs at community clinics, so I know it's done.  But you know, ClinkShrink doesn't like benzos at all, ever (per The Benzo Wars, if you'd like to hear us shriek at each other), and the rest of us Shrink Rappers don't like Xanax in particular.

Time to wake up, Roy.

Wednesday, September 14, 2011

Why I Am Happy That I Am Not a Child Psychiatrist

My hat goes off to kiddy shrinks.  It's a tough field, full of issues we don't see in adult psychiatry.  
Our comment section often buzzes with talk about the over-diagnosis of bipolar disorder in children and the ethics of giving psychotropic medications to children.  The Shrink Rappers never comment on these things.  Why?  Because we don't treat children.  I have no idea if the children being treated are mis-diagnosed, over-diagnosed, wrongly-diagnosed, or if the increase in treatment represents a good thing---- perhaps children who would have suffered terribly now are feeling better due to the option of medications.  I've certainly had adult patients tell me their children were treated with medications, the children have often eventually stopped the medications and emerged as productive adults.  Would they have outgrown their issues anyway.  Or did the treatment they received switch them from a bad place to a good place and enable them to carry on in a more adaptive way?  Ugh, my crystal ball is on back-order at Amazon!  

Why I'm Happy I'm Not A Child Psychiatrist:

  • Two extra years of training (and being on overnight call)
  • No extra pay.
  • "Normal" or "well" children often display behaviors that look a lot like those of "ill" children.  Ever witnessed a temper tantrum? 
  • Children often can't verbalize their feelings and they are inferred from behaviors. 
  • Children are often subjected to the treatment, with all it's options for distress-- whether it be that therapy displaces soccer or that Risperdal causes sluggishness-- without the same open dialogue and choice that adults get.
  • Children are often treated based on the distress of other people.
  • Some illnesses in children are defined by the arbitrary standards of societal expectations.  There would be fewer hyperactive children if we didn't expect boys to sit still for long periods of time.
  • It's very hard to differentiate a "phase" that will be outgrown from "pathology."  This is especially true in teenagers where some angst and rebellion are part of some people's journey.
  • There are times when treatment is based on the reports of others (such as parents) and there is no guarantee that such reports are accurate or that the parent's expectations are reasonable/realistic, and parents can be quite demanding about the need for treatment and medications.
  • It can be difficult dealing with the troubled parents of troubled children.
  • Expanding on that, parents sometimes get angry and remove their children from treatment if it is suggested that they are part of the problem.
  • I don't like treating people who don't want help and children are sometimes in treatment at the request of their parents, schools, or other agencies.  True for adults as well, but not in my office.

Monday, September 12, 2011

Howard Dully's Lobotomy

If you're looking for a reason to hate psychiatry, I found it for you.  I just finished reading My Lobotomy by Howard Dully.  It's his memoir, focused around the event of a transorbital "ice pick"  lobotomy which he underwent at the age of 12.  Twelve.  Oy. 

Dully talks about his devastating childhood--- his mother died of cancer when he was five, and his father remarried to his evil step-mother.  He spends a lot of time making the case that she was the problem and he was a normal kid.  At the time of the lobotomy, he was going to school and had a paper route.  He does describe himself as a kid who might have had behavior issues (for any one of many reasons).  His step-mother seeks the advise of psychiatrists, and Dully says she was unhappy with the suggestions she got-- namely that she was the one with issues.  Until she met Dr. Walter Freeman.

Dr. Freeman is credited with performing over 3,000 lobotomies.  He traveled around the country in his own vehicle, which he dubbed the "lobotomobile" and performed transorbital lobotomies by inserting a sharp object through the eye sockets.  No open surgery required.  No anesthesia required (he used electroshock to render his patients unconscious).  

In 1960, Howard Dully had a lobotomy.  He had seen Dr. Freeman for 4 visits.  He was diagnosed with schizophrenia and was offered no other form of treatment.  No therapy, no medication, no hospitalization.  He was told he would be undergoing testing and was not told about the lobotomy until after it was done.

It's a chilling read, one that still lingers with me days later,  and the book was written after NPR did a story on Howard Dully.  You can listen to that here:

Not one of psychiatry's finer moments.

Sunday, September 11, 2011

Never Forget

Like Dinah, I also was thinking of writing something. I went to Twitter, and saw that many people were saying what they were doing at the time of hearing about the attacks. It made me think -- for the umpteenth time -- where I was and what I was doing at that time.

If any of you readers would like to describe what you were doing on 9/11/2001, the day of the terrorist attacks, please feel free to do so in the comments.

I was in my private practice office at GBMC seeing my first patient of the day. A very healthy, but very anxious older man with frequent physical complaints. Very nice guy. We were just finishing a therapy session (~8:50am) and I sent him out and was writing my note. My office was in a hospital office building in a suite run by a primary care physician, so there were also several exam rooms, a large front office with a receptionist and two office staff, and a waiting room with maybe a dozen chairs.

The first plane hit at 8:46 am ET (detailed timeline here on Wikipedia).

My 9am patient, a middle-aged woman with even more anxiety problems whom I had helped with a severe benzo addiction, came back early to tell me that a plane had crashed into one of the twin towers in NY and that another one was heading to DC. My initial reaction was disbelief. She must have gotten that wrong. I go out to the front office where everyone is crowded around a TV, listening to the news. My 8am patient is still there.

She was my last patient of the day. Everyone else cancelled. If they hadn't, I would have. The day was filled with fear, uncertainty, and doubt. But there was a camaraderie. We all grew closer with this common experience. The images, burned into our collective brains.

The one peaceful image that equally burned into my brain: for four days I gazed for long periods at the sky in amazed wonder. Not a single plane. Not a single jet entrail drifting across the sky. "This must be what the sky looks like in Wyoming," I recall thinking. Beautiful! I'm tearing up just thinking about it now. I've still never made it to Wyoming. But I will never forget.

Remembering September 11th

One option was to let the day pass without a blog post.  The other was to say something about the fact that it's September 11th, a day that left so many people so distressed.  It was never an option to post on an unrelated topic.

I find myself pushing thoughts of that day out of my head, and then, periodically, I'm drawn to watching a YouTube video of the towers falling.  Mostly, though, I've had nothing to say because what is there left to say?   It was horrible. 

My patients have not been talking about 9/11.  They all want to tell me where they were during the earthquake that shook us a few weeks ago, and whether they lost power during Hurricane Irene.  I'd asked a former guest blogger who lives in NYC if he wanted to write about 9/11, and he said he'd think about it and I haven't heard back.  Another friend was standing under the towers when they collapsed.  I asked if he'd like to write for a psychiatry blog and he said he'd been unable to write about it, perhaps in his memoir, and last year he left the country on the day.  This was a tragedy that evades words and pulls us to places that are difficult to go.  I want to thank David Hellerstein, again, for writing a guest post for us on Resilience in honor of the anniversary.  When I first read his post, I liked it, but I thought it was about resiliency, and not the aftermath of the terrorist attacks.  Perhaps that is truly the best place to go as we all carry on with hope in our hearts.

And finally,  I'd like to link to a memorial note for for my friend, Carlos DaCosta.

Peace to all.

Saturday, September 10, 2011

Looking for Psychiatrists for APA Talk in May on New Media

@ 2011 AVAM Kinetic Sculpture Race

I'm moderating a panel discussion about Psychiatrists and the New Media at the May 2012 APA Annual Meeting, and I have two slots left for the panel. It will include a brief presentation (5-7 min) from each participant, followed by a panel discussion and audience questions.

If you are a psychiatrist attending the meeting and would like to be on the panel, please email me (shrinkraproyATgmail) or comment here. I'll also write a blog piece next year with highlights from the session for our readers.

[At right, I shot this pic of a toddler fascinated by the bubbles from the bubble machine at the 2011 Kinetic Sculpture Race at the American Visionary Art Museum in Baltimore.]

Friday, September 09, 2011

More on the Shrink's Notes...

Please see my post on Clinical Psychiatry News and yesterday's post What's in a Note? along with the reader comments. 

One reader asked why it's weird to want to see your shrink's notes and why shrinks refuse to show them on the grounds that they may distress the patients.  Another reader asked why doctors write "patient denies" as though they don't believe the patient.  These are both great questions worthy of their own post.

Why don't psychiatrists like to show patients their notes?  Are they really going to "harm" the patient?  There are a few reasons why a psychiatrist may not want to show a patient her notes.  Here is my list of thoughts as bullet points. Please feel free to add to it.
  • Doctor-speak can be cold and clinical and the shrink may worry that the patient's feelings will be hurt.  It can all be quite distancing and who wants to be viewed through the eyes of doctor-speak?
  • The doctor may have things in his notes that the patient views differently.  For example, a patient may be angry that the psychiatrist does not believe him that martians monitor his movements with special cameras inside his body and may want it removed from the chart that he has  "delusions."  I could come up with many more examples.
  • The shrink may be concerned that the patient will misinterpret things he's said and be upset by them.  
  • The shrink may be embarrassed that he has lousy notes.
  • Shrink talk can be rather detailed and insulting.  The mental status exam includes a description of the patient-- the patient may feel very hurt to know his doctor saw him as "unkempt" or noticed he was unshaven, or "malodorous" or that he appeared agitated or anxious.  These are descriptive and therefore useful from a clinical standpoint, but they can also be read as insulting and the patient may feel injured, or put the psychiatrist in an awkward spot if he demands something be changed when the psychiatrist doesn't agree. More importantly, reading something uncomplimentary may damage the relationship.  People want their shrinks (particularly their therapists) to think well of them, and how do you continue to have a warm and fuzzy relationship with someone who has written that you smell bad? 
  • The shrink may worry that the patient will sue him or file a complaint.
  • The patient may want things taken out of the record even if they agree they are true.
  • I think mostly it's about avoiding confrontation, but tell me if I'm wrong.
Psychiatrists are taught to report things in a specific way, and doctor-speak has it's own nuances that don't match everyday English.  There is the 'chief complain'-- oh but saying someone is complaining is pejorative, it's like saying they whine!  We think of it as a problem list, but 'complaint' is the medical term.  Similarly with "denies," though I've heard others say that it sounds like we don't believe the patient, and I've come to avoid the term, except if I don't believe the patient, and then I may say why: "denies depression but sobs throughout the session and looks miserable."   

Tell me what you think.

Wednesday, September 07, 2011

What's in a Note? Psychiatrists and Medical Records

There's lots of talk about Electronic Health Records and where the information goes and who has access to it, with the assumption that easy communication is mostly a good thing.  EHR's, cloud storage, and all there is to argue about aside, let's put a question out there: What's in a psychiatrist's note, anyway?  For the sake of our hypothetical discussion here, let's skip the evaluation note, and just talk about progress notes.  Oh, if you'd like to know what's in a psychiatric evaluation, buy our book, we go on and on (and on) about what happens and what gets written.

The progress note is a different story, especially when the treatment includes psychotherapy.  Some psychiatrists write a lot, some write a little, and I wrote all about it over on our Shrink Rap News blog, so please do surf over to read "You Don't Say: Psychiatrists and Their Notes."  

If you're a psychiatrist, what do put in your progress notes?  If you're a patient, what do you imagine (or know) is in your chart?  If anyone worries about such things, please do tell us what your concerns are. 

Monday, September 05, 2011

How to be a Successful College Student

It's Labor Day and kids are getting ready to go back to school.  The Shrink Rap duck pictured here is getting in his last moments of holiday relaxation, and I am so happy to be up and running on my new Macbook pro.

Here at Shrink Rap, we don't offer medical advice, so this is not medical advice.  It's not based on anything even vaguely resembling evidence-based medicine, but I have treated many college students over the years and I have been impressed by those things that seem to make or break the college experience.  Back-to-School, but none of us treat the under-18 crowd, so my bullet point suggestions are limited to college students.  If you're a parent, feel free to send this to your college student, and if you're a student, feel free to ask "Who are those blogging shrinks with the duck? They must be quacks." 

Here are my quick & dirty pointers for how to succeed in college:

1) Show Up.
Being present in class, on time, in a state that vaguely resembles conscious is most of the battle.
If you don't go to class, with the exception of the unanticipated onset of a febrile or gastrointestinal illness, then you should know well in advance that you're not going to go and have a strategy for how you are going to make up the work.  By these criteria, "I don't want to get out of bed" doesn't work.  But "The professor doesn't speak English and lectures straight from the book, so it's a better use of my time to read the book and get notes from my roommate who takes great notes," may be a valid reason to skip class.

2) Don't smoke weed.
This is a tricky one-- many college students smoke weed (or at least those who end up my office almost all do).  Some people smoke marijuana regularly and still seem to live fully productive lives.  Some people seem to find it very "beneficial" to them even though it appears to be killing their motivation and decreasing their anxiety to the point where they have no ambition, barely move,  and don't do the things it's necessary to do in order to succeed, for example #1 above: Show Up.  Oddly enough, marijuana smokers do not see the connection between their  low motivational level and their low success status and they are absolutely sure their consumption of marijuana has nothing to do with their problems.  They become very skilled at telling others why weed isn't part of the problem and many are quite well versed on the rhetoric of NORML and how the it's a political agenda to keep marijuana illegal.   If you're not successful and you smoke weed, stop and see if your life gets better.  Oh, and by the way, two weeks off is not a 'trial.'  Don't smoke at all, ever, for 6-12 months and see if you're in a better place.  If you are successful and you smoke weed, you're probably not reading this article, but even in the best scenarios, it increases your risk of lung cancer and it causes the munchies which can make you fat, and if you get caught and arrested it's a lot of explaining to do for a very long time.   

3) College Students and Drinking.
This is even trickier because while there are college students who don't smoke weed, the role of alcohol in college life is huge and the pressure to drink is immense.  It's not legal if you're under 21, it seems to lead to all sorts of problems, but it seems to be an impossible sell to college students, so let me make suggestions based on the assumption that there is nothing I can say that would stop anyone from drinking:
--Don't drink on any night when you need to be somewhere the next morning.
--Don't drink enough that you vomit, pass out, or black out.
--Don't drive after you've had anything to drink: being dead is a lot worse than not finishing college.
--Keep your total consumption under 15 drinks a week for a man and 8 drinks a week for a woman.
--If you can't keep abide by the above suggestions, you have a problem and should get help.
NPR had an interesting show on Why College Students Drink So Much and Party So Hard about a book by Thomas Vander.
Add to the How to Stay Alive Issue :  Before you go out drinking, Eat.  If your friends pass out, roll them on their side and don't ever leave someone who is passed out alone.  If they really can't be aroused to at least push you away and groan, call an ambulance.  Don't do shots.  Beer pong is more fun and much safer. Don't drink in settings where you may be sexually vulnerable.

4) Get enough sleep.
If this means not scheduling early classes or taking naps during the day, then consider those things when you set your schedule, but sleep is really important.

5) If you have a psychiatric disorder, don't stop your treatment.
It's not unusual for kids to try this when they go off to college and don't have the 'rents handing them medications or driving them to therapy appointments.  It's a really bad idea.  Particularly bad times to cease treatment are first semester Freshman year and any year during mid-terms or finals.    I'll add: if you have a psychiatric disorder, don't drink, it makes everything worse.

6) Take a large, heavy brick and throw it through your Nintendo/PlayStation/XBox.
  Ditto for online fantasy games.  Anything outside of school work or employment that captures you for more than two hours a day may be a problem.  Reading psychiatry blogs is fine.

7) If you're a sensitive or problem child, don't have a roommate who shares the same bedroom with you, it adds to the stress of college and it's helpful to have space you can escape to.

8) If you're having a rough time, get help.
If you're struggling in class, talk to the professor and consider getting a tutor.  If you're very depressed, call the counseling center.  If you're feeling sick, go to the health center.  College is not the time to suffer alone.

9) Know the final drop date for your classes and if you're failing, drop the class.  Remember to turn in the form.

Anyone want to add to the list?
Best wishes for a happy, fun, and educational school year.

Thursday, September 01, 2011

Guest Blogger Dr. David Hellerstein on Trauma and Resilience, Ten Years after 9/11

All New Yorkers have vivid memories of the events of 9/11/2011; and for New York-based health care workers our memories are generally mixed with feelings of frustration and helplessness. We recall how we emptied out hospital beds that day, how we were prepared in emergency rooms and clinics, and how we waited hour after hour—in expectation of a flood of patients that never came.  And we recall how in the ensuing days, weeks, and months, survivors finally entered our offices, clinics and hospitals, seared by memories and nightmares and visions they could not erase.

Patients working on Wall Street, living in Battery Park City or in lower Manhattan, those who were evacuated by boats from apartments located close by the base of the towers, people who happened to be shopping or walking in Lower Manhattan that Tuesday morning, firemen who rushed to the site of the rubble, parents who were scheduled for meetings at Windows on the World restaurant, but had to drop their kids off at school first, people who heard the first impact, and—remembering the prior attack on the WTC—immediately  left the buildings and headed North, people whose apartments were destroyed or cars were crushed or jobs were eliminated…or people who waited in the suburbs for a spouse to return on the MetroNorth commuter train, and finally concluded they would never return.  They all came, looking for help.

We remember equally vividly how many months and years it took for recovery to begin. We worked intensely to enhance the process of recovery, whether through medical treatments or psychotherapy.  All of us, patients and doctors alike, were haunted by the memories of those who never emerged from the rubble, and by the randomness of survival.  And yet we patients and doctors had a unique cameraderie as well—a feeling that we were all in this together, united against a common, though perhaps unseen, enemy.  Surely this helped with recovery, along with the expectation that life would eventually return to normal. 

For neuroscience researchers, the events of 9/11 were a sort of natural experiment, similar to the events of war.  Over the past decade, there has been significant progress in understanding the brain’s responses to trauma and what causes PTSD, and as well as understanding what may help people to recover from such cataclysmic events. It has become abundantly clear that the brain’s fear systems, commonly associated with the center called the amygdala, have incredibly tenacious memories for trauma that are extremely difficult to dislodge.

New research has brought illumination and hope to these issues.  NYU researcher Elizabeth Phelps is doing research on the neurological processes involved in the consolidation of traumatic memories, which indicates that there may be a window of time during which the deposition of such memories can be interrupted. Will this eventually provide a way to prevent PTSD, either by new types of psychotherapy or by the development of new medications that can block the deposition of such memories?

On a broader level, the events of 9/11/2001 have underlined the importance of resilience.  Some survivors of 9/11 quickly returned to their usual level of functioning, yet many others, a decade later, are still haunted by those events.  Resilience, or the ability to survive or even thrive under stress, is being studied as a neuroscience-based process. Researchers such as Avram Caspi have determined that there are genes related to resilience. Other researchers have described behavioral characteristics that are related to higher levels of resilience, such as Charles Nemeroff and Dennis Charney in their book The Peace of Mind Prescription.  (Resilience is one of the 6 key New Neuropsychiatry principles described in my book Heal Your Brain and in my blog at

Just to mention one key element of resilience: appraisal.  Appraisal means the way in which we interpret events.  If an event is interpreted as a threat, it evokes fear responses, including activation of the amgdala, and a series of physical responses including release of cortisol and stress hormones. Yet if an event is interpreted as a challenge, it evokes a different series of responses, including interest, calm, relaxation, and adaptive coping. And as Nemeroff and Charney note, “The hormones released by an appraisal of challenge include growth factors, insulin, and other compounds that promote cell repair, trigger relaxation responses, and stimulate efficient energy use.”

The components of resilience include:

·      Physical resilience, physical ‘toughening’ and ‘tempering’
·      Psychological resilience “situations are viewed as challenges, not threats”:
·      Activating social networks, including confiding relationships
·      Adequate external supports
·      Challenging one’s self
·      Looking for meaning through involvement
·      Learning

Now, a decade after 9/11/2001, it is possible to have almost a strange nostalgia for that moment, since we live in a world with increasingly huge problems but without clear solutions, in which day-to-day stresses seem to be continually increasing, with worsening financial and political instability, and increased polarization between incompatible world-views.  In attempting to cope with all of these ongoing and much less clearly defined stressors, the question is, what can help?

In my view, resilience is key.
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