Wednesday, May 30, 2012


What’s your mental health number?
This is the question that the Bipolar Collaborative is asking, using its WhatsMyM3 screening tool [PubMed]. “Many other illnesses have a 'number' that one can track – cholesterol, high blood pressure, diabetes. What’s the number for mental health?” asks Michael Byer, president of M3 Information, based in Bethesda, Md.
~from Clinical Psychiatry News

Today's USA Today newspaper ran a story titled, "Screening for mental illness? Yes, there's an app for that," by Michelle Healy.

WhatsMyM3 is a validated, 3-minute tool that screens for symptoms of depression, bipolar disorder, PTSD, and anxiety, and can be used to monitor changes in symptom severity over time.

One of the developers, Michael Byer, approached me about a year ago for my opinions on development and use of the screening tool. Disclosure: After reviewing the research and seeing how useful it is, I have become more involved in the organization, becoming an adviser to the group that was started nearly ten years ago by past NIMH chief, Robert Post MD. (listen to podcast #63)

It differs from other mental health screening tools, such as the PHQ-9 and the MDQ, in that these are all unidimensional -- they only measure one domain of symptoms. The M3 is multidimensional, measuring four areas of symptoms. Furthermore, when compared to results from the standardized interview tool, the Mini International Neuropsychiatric Interview (the MINI measures for 15 different mental illness diagnoses), WhatsMyM3 provides a total mental health score that is 83% sensitive in finding true positives and 76% specific in finding true negatives. In addition to the total score, there are four subscores, one each for depression, bipolar, PTSD, and anxiety.

Put another way, the negative predictive value of the total score is 89%, meaning that if you score under the threshold, there is an 89% chance that you do not have any mental health diagnosis by the MINI. As with most screening tests, you want the negative predictive value to be high so that you don't have to subject the "negatives" to more specific testing. The positive predictive value, or PPV, is generally lower for screening tests. It is 65% for WhatsMyM3, meaning that if you score positive (total score >= 33 and positive for functional impairment), the odds of you having a diagnosis is almost two-thirds. A clinical evaluation can then help to determine if you do have a diagnosis. (Note: this tool cannot give you a diagnosis; it can only describe your relative risk of having, or not, a diagnosis.)

What people have found to be most helpful is using WhatsMyM3 to monitor their symptoms over time once they do have a diagnosis. This can be done for free on the website, or for $2.99 using the iPad or iPhone apps, or the Android app. For mental health clinicians, they can download the free M3Clinician iPad app and then screen their own patients. For about a dollar per screen, they can register their patients who want to track their symptoms over time and share their scores with the clinician. Primary care providers also purchase screens, and can even obtain insurance reimbursement by billing for an annual health risk assessment. The patient reports can be viewed by logging into

A sample report for a fake patient can be viewed here.

I think this sort of tool, or app, is exactly the sort of mHealth thing that empowers consumers to better manage and become engaged in their health care needs. This is happening in other areas, like diabetes, heart disease, and obesity. Mental health is also making great strides in mHealth.

I should also point out here that the folks at M3 Information were the only ones to take us up on our offer of a free "advertisement" on Shrink Rap in return for donating at least $200 to our NAMIWalk for Mental Health Month (we don't typically accept display ads). A logo ad will be running soon on Shrink Rap soon for two weeks in recognition of their charitable donations. It will look like this and link to the iPhone and Droid apps. [We received no money ourselves from M3 nor from NAMI. We've never accepted any money from Pharma companies, nor does M3.]

An Open Letter to HealthGrades: Are Online Doctor Reviews Always Valid?

I Googled myself recently to discover a one-star rating of my practice on HealthGrades.  The rating wasn't just a rating on the HealthGrades site, it showed up on the top of the first page of search results, a public announcement to anyone who Googles me.  

I contacted HealthGrades and asked them to please investigate as I did not believe this was a review from one of my patients.  Because the facts in the review were simply inaccurate, the one-star review of all aspects of my practice seemed to be vindictive, not an accurate assessment of my psychiatric practice. 

On our Clinical Psychiatry News website, I  will discuss in more detail what happened transpired when I asked HealthGrades to investigate.  To those who hate waiting for end of the story: They took it down.  
Here, I want to tell HealthGrades why I don't believe this was posted by any of my patients.  Below is my open letter to the HealthGrades leadership team

Dear HealthGrades:

You've taken the liberty of listing me on your site without my permission.  You've put up my name, an incorrect address with a click-on map providing directions to my previous office, my age (which this week, I'm feeling a bit touchy about), medical training, an inaccurate list of insurance companies which you claim I participate with,  and you've provided a venue for any human being with Internet access to post a review and write comments about me. There is nothing to assure that a review wasn't written by a neighbor who is  angry that my dog got into their yard, by one of the 47 commenters who has asserted that I'm an idiot for writing a Baltimore Sun op-ed piece in opposition to medical marijuana legislation,  by  someone who disagrees with something I have to say here on Shrink Rap (where we do periodically host some discord),  or by a patient who is displeased that I won't prescribe an addictive medication that is not indicated for their condition. There is also nothing to prevent me from posting 5 star reviews of myself.

Many patients Google doctors before they see them, and whether or not you believe a single review (there is only one) has any weight, at some level, people see it and process it.  I Google my doctors before I schedule a first appointment, and I might not go to someone with a one-star review.  All in all, I feel violated that you've posted this information and have permitted an unchecked venue for all commenters.   The one-star appearance on my Google search page may damage my professional reputation and may have financial repercussions for me.  Certainly there are bad doctors out there, but I am not one of them, and allowing an unverified reviewer to say that every aspect of my practice is unacceptably poor, constitutes slander.

I don't believe that the review was written by one of my patients, and let me go through each of my one-star items and tell you why I think this was an internet hater and not someone who knows me.

I've copied and pasted the HealthGrades categories you've established for doctors to be rated on.  For each of these categories, I was rated one-star out of a possible five stars.
Scheduling Appointments:
Ease of scheduling urgent appointments when you feel ill:
-----Any established patient who calls and says their problem is an emergency is seen that day or the next. Every patient is given my cell and home phone numbers before our first meeting, I respond to calls and texts within the day, sooner if they are urgent, and I do my own scheduling.  It generally takes days, and not weeks, to get an appointment, even on a non-urgent basis.

Office Environment:
Office environment (cleanliness, comfort, lighting, temperature, location):
----- These are individual taste issues.  The office was built out to my specifications, with neutral decor and a fair amount of attention to the environmental factors that I can control.  It is in a professional building, in a safe part of town, surrounded by shops and restaurants, and a janitorial service cleans the suite on a daily basis.   

Office Friendliness:                                                       
Friendliness and courtesy of the office staff:
----- I don't have office staff, but I wish I did.

Wait Time:
Once you arrive for a scheduled appointment, how long do you have to wait (including waiting room and exam room) before you see this provider:
----- In 20 years, I have never run 45 minutes late.  I can count on one hand the number of times I have run 10 minutes late. I start almost every session within 5 minutes of the scheduled appointment time.

response:Over 45 Minutes

About Dr. Dinah

Level of Trust:
Do you trust your provider to make decisions / recommendations that are in your best interests?
--- I can't fully address this-- trust is something that happens inside an individual's head.  I certainly believe that I have my patient's best interests in mind when I make a recommendation, people often tell me they trust me, and no one has ever said that they don't trust me.

Helps Patients Understand Their Condition:
Does the provider help you understand your medical condition(s)?
---  I believe I'm actually pretty good at articulating psychiatric conditions, I've had a bit of practice over the years.  

Listens and Answers Questions:
Does the provider listen to you and answer your questions?
--- I always ask new patients if they have any questions.  I  invite people to call or text me if they have concerns between sessions. I practice psychotherapy, so by definition, I listen.

Time Spent with Patient:
Do you feel the provider spends an appropriate amount of time with you?
-- I spend two hours on the first evaluation  and 50-55 minutes with each subsequent therapy session, unless a patient specifically wants a half hour session.  I'm happy to schedule longer appointments with anyone who'd like them, but no one has ever asked.

The response I got from HealthGrades, which I'm perplexed by, but not completely  displeased with, is that because I'm in the mental health field, they will take the review down.  They did not attempt to reach the reviewer.

If you are a mental health professional and want those bad reviews to vanish, remember to check your profile daily, and remember to request to have those ratings removed.  Funny, they don't publish this policy anywhere, so I'm taking the liberty of doing it for them.  If you're a patient looking for a good psychiatrist, remember that those with good reviews aren't going to ask to have them removed, so the ratings are biased in favor of the clinician.  From what I can tell, this site serves no one well.

HealthGrades' email address and a contact form are easily found on their website, and if that doesn't work, their phone number is 303-716-0041.  I got to a live person fairly easily and there was no wait.

Addendum: I wrote to their public relations person and asked them to remove my profile, and it was removed this morning. 

For more about my interactions with HealthGrades, see the Clinical Psychiatry New article Here.

Sunday, May 27, 2012

Should Doctors Feel?

There was an article in today's New York Times called "When Doctors Grieve."  Leeat Granik mentions her mother's long battle with cancer and the family's relationship with her oncologist.  She is now a health psychologist and has just published an study done by interviewing 20 Canadian oncologists.  While I know nothing about the methodology she discusses, I found her conclusions, as she summarized them for the NYTimes, to be thought provoking:

We found that oncologists struggled to manage their feelings of grief with the detachment they felt was necessary to do their job. More than half of our participants reported feelings of failure, self-doubt, sadness and powerlessness as part of their grief experience, and a third talked about feelings of guilt, loss of sleep and crying.
Our study indicated that grief in the medical context is considered shameful and unprofessional. Even though participants wrestled with feelings of grief, they hid them from others because showing emotion was considered a sign of weakness. In fact, many remarked that our interview was the first time they had been asked these questions or spoken about these emotions at all.
The impact of all this unacknowledged grief was exactly what we don’t want our doctors to experience: inattentiveness, impatience, irritability, emotional exhaustion and burnout.
Even more distressing, half our participants reported that their discomfort with their grief over patient loss could affect their treatment decisions with subsequent patients — leading them, for instance, to provide more aggressive chemotherapy, to put a patient in a clinical trial, or to recommend further surgery when palliative care might be a better option. One oncologist in our study remarked: “I see an inability sometimes to stop treatment when treatment should be stopped. When treatment’s futile, when it’s clearly futile.”

I wondered if  one or two (or a few) psychotherapy sessions might help doctors who deal with death or other difficult patient issues?  Might brief psychotherapy give these doctors a chance to  express and explore difficult emotions in way that might make them more comfortable with their feelings --even social or culturally unacceptable feelings-- and be more aware of how these feelings are impacting their work?  It's just a moment of wonder.  I don't want this to be read as a wish to medicalize normal emotions or to suggest that all oncologists need long-term psychotherapy, or that such a thing even be required, it's  just a question of 'what if' such a venue were easily available in a non-stigmatizing environment?  What do you think?  Maybe it's just the sort of thing one should feel comfortable talking with colleagues, or a nice spouse, about, though I think the point of the article was that it isn't okay to talk about these things without being seen as weak or troubled.

Wednesday, May 23, 2012

A Pill for Alcoholism?

When I was at APA earlier this month, I heard an excellent talk by Dr. Bankole Johnson on the treatment of alcoholism.  I'm currently reading a book called Hooked, by Lonny Shavelson, about an effort by the San Francisco Department of Health to provide drug-treatment-on-demand to all comers in 1998.  The book, a great read even if it is a bit out-of-date, talks about how drug treatment gets divided into camps of those who insist on total abstinence versus those who will settle for a decrease in use as part of the "harm reduction" model.  Dr. Bankole made the point that if you look at total abstinence for alcohol, the numbers are low and one could get very discouraged trying to treat alcoholics.    And he is all in favor of trying medications to reduce craving for alcohol.  Which brings me to an article in the NYTimes by Douglas Quenqua called "Drugs Help Tailor Alcoholism Treatment."  So Dr. Johnson is quoted in this article, and since I enjoyed his talk, I'll mention the article.  It talks about medications that help some people with their cravings-- both on label and off label-- and the question of using a pill to treat an addiction.

Tuesday, May 22, 2012

Books and Ducks

Life is quiet here as we get ready for summer.  Nothing has struck me as particularly urgent to blog about, but Sarebear sent us a link to a mystery writer's blog with a post about shrinks in mystery novels, so I thought I'd share that:

We haven't been able to find time to podcast, it seems we're never around all at the same time.  Clink is off touring nature sites and playing with her new camera.  Maybe she'll post a pic?  Roy is busy with all thinks geeky, and I'm happy that I finished a grant application today-- my first ever.  I've been fiddling some with my old fiction, and I'm thinking of putting one of my old novels up as an e-book on the free amazon kindle site.  Has anyone done this?  Do you have any wisdom to share with me?  Oh, and speaking of e-books, I just got a copy of Lowell Handler's new e-book, Crazy and Proud.  Do check out his website.  I haven't read the book yet, but the photography is compelling.

So I thought I would check out Facebook advertising.  My cousin used it to get thousands of fans for her website,, about mother-daughter relationships, so I wanted to see how it worked.  I ran the ad for 2 days with our book cover as the graphic and only got one click-through.  I changed the graphic to a duck, and there were 6 clicks in following 24 hours.  I feel like I'm turning into Roy with all this number tracking.  It's just an experiment to see how it works (another Roy-type thing to do).

Finally, the graphic above was sent to me from a blogger at a site called Grass Fed Ducks, which I think is mostly about food (specifically Korean Food), but there is a duck/mental health tinge as well.

Friday, May 18, 2012

Shrink Rap Ads for NAMIWalks Donations

Click image to Donate.

Shrink Rap is walking for NAMI's Donation Walk tomorrow, Saturday May 19, at Baltimore's Inner Harbor (Rash Field), at 11am. Looks like medical blogger, Dr Val Jones, will also be joining us. Roy and Dinah will be there (I think Dinah; she said she might). Clink will not be able to join us.

But, as you can see on the left, we have only hit 21% of our goal. Sure, it's $300 more than last year and I probably over-reached, but I'm not giving up yet.

Here's the deal. If anyone donates at least $200, we will donate one week of advertising on Shrink Rap, right in the header where the lime green ribbon is now. That's about 8000-10,000 pageviews and potentially 300+ click-throughs. (No pharma, no distasteful ads. Sorry if this seems cheesy but it's for a good cause.)

And, if you are in town, feel free to join us Saturday morning. Registration begins at 10am. Thank you.

(Also, thank you to our recent contributors: Lawrence, Dave, Julie, Dinah, Elise, Carol, Elizabeth, Amy, John, Colleen, Michael, Valeria, and several Anon's.)

Thursday, May 17, 2012

Conversations About Bipolar Disorder

Sara is a blog reader who wants to write about bipolar disorder.  She's interested in talking to people who have the condition, and she's started a blog called "Conversations about our Condition."
If you wouldn't mind talking to her, do visit her site!

Wednesday, May 16, 2012

Fatter and Fatter

I have some questions about America's obesity epidemic.

The New York Times has an article about a mathematician who has been looking for the causes of obesity-- In a A Mathematical Challenge to Obesity, an interview with Carson Chow, Claudia Dreifus  notes that the average person weighs 20 pounds more now than in the 1970's.  I was alive then and it was the hey-day of processed food back when skinny people fed their skinny kids white bread with butter and sugar.   Mayonnaise (or rather Miracle Whip, what ever substance that might have been) was on everything, and oh for  twinkies, ring dings, chef Boy-r-Dee, and scooter pies....those were the days.

The mathematician proclaimed that the answer is that there is more food.  More is grown, more is available, it's cheaper and cheap food allows for the existence of fast food, something you can't have if the food costs a lot.  What I've noticed is that food is everywhere.  All the push to make school food healthier, get rid of soda machines, and encourage children to be more active (ah, the kids I know, even the heavy ones, are doing 3 hours a day of sports after school, it's no guarantee you'll be slender), but it seems that every day is a "special" day....a fund raising bake sale, someone's birthday, end of year party, weekly advisory where the kids rotate bringing baked goods, language class meal, trip to restaurant, snack parent at every sports game, followed by dinner, and when you go out, the servings are huge, and I, for one, find it hard to stop eating really good tasting food if I'm hungry and it's on my plate.  So I'll believe that food availability is the reason why people are fatter.  

So here's my question.  Obesity researchers study obese people and how they differ from normal weight people.  Why isn't everyone obese?  Why are only 1/3 of Americans  obese and only 1/3 are overweight?  Why aren't they studying the people who remain thin despite the fact that they are surrounded by food? Okay, so some people have very fast metabolisms, but others are don't seem to have any desire to overeat.  There may be lots of available food, but they don't want it, or they want it when they're hungry, but they have some and that's enough, a 'stop eating' mechanism kicks in at a point that keeps their weight low.  Why don't they have the desire to eat more when food is available?  And finally, there are those people who want more food, but for the sake of their health or their appearance, they limit their eating.  I've heard it said, "Well, if she really wanted to be thin, she'd eat less."  I don't buy it, I think there are differences between people besides a simple desire, or a weakness of character that makes self-control harder for some then for others.  I want to know why some people have faster metabolisms, less desire to eat, or more will power.  Okay, Dr. Carson, how does your mathematical model work for that one?

I'm not an alcoholic.  It's not because alcohol isn't available-- at any given time my house is stocked with an assortment of beers (I keep dark on hand because Roy likes it) and wines.  It's available, but most days, it's just not on my radar.  It's not because I have great willpower.  I like a drink or two, but after that I get very tired, and it's not fun to be out with people just wishing I could lie down.  I'm not an alcoholic because I'm not wired to want  to drink very often or very much.  I tend to think it's the same with obesity: some people crave food, or the wrong food, or way too much food, and others don't.  Availability may make it easier, but there are still thin people, and isn't it interesting that in more affluent socioeconomic circles, where food has always been readily available, obesity rates are lower.

As a society, we've made the statement that if you're fat, it's your fault.  The obese are the last group of people that it's okay to pass judgement on.  "Exercise more, Eat less."  It's a simple recipe.  Dr. Chow tells us there's no magic bullet.  It's stigmatizing to take weight loss pills or have bariatric surgery.  I've heard morbidly obese people say it's their own fault, as though they don't deserve to be thin, and they loathe themselves for eating too much.  I sometimes wonder if our prejudices about obesity hinder pharmaceutical research because-- if anyone wants my vote-- there should be a magic bullet. 

Tuesday, May 15, 2012

Crossing Over: Treatment Rights of Transgendered Prisoners

Over on Clinical Psychiatry News I've put up a column on the evolving treatment rights for prisoners with gender identity disorder.

In the CPN post I cover about thirty years worth of changes in prison policies and standards, up to where we are today: individual inmates suing prisons to provide sex reassignment surgery. So far no inmate has ever been given surgery, but at this point it's just a matter of time.

I think the topic is interesting in part because it traces out how correctional standards of care develop: first the courts decide if a condition "counts" as a serious medical or mental health disorder that mandates treatment, then over time an accumulation of individual cases carve out the boundaries and limitations of that care.

So why aren't doctors the people deciding this instead of judges?

Well, they are to an extent. The institutional clinician assesses the condition and makes a determination of treatment needs. Outside clinicians acting as court consultants or correctional experts offer opinions about what the standard of care should be, and professional organizations also weigh in. Courts take in all of this information, weigh it against the interests of the facility, and issues an opinion about whether or not there is a constitutional right to treatment.

This is the same process that took place in the 90's when protease inhibitors were invented to treat HIV. Correctional facilities initially balked at giving the meds because of the cost, but now this is standard and accepted.

Feel free to post questions or comments in either place (CPN or Shrink Rap).

Sunday, May 13, 2012


Happy Mother's Day, everyone.  I've had an exhausting day.  I asked to go hiking and spent three hours on a mountain.  Oh...I'm tired.

Okay, you know that none of us are child psychiatrists, but a number of kiddy issues have hit my radar, so just a very quick recap:

Over on Clinical Psychiatry News, I did a book review of Kaitlin Bell Barnett's new book Dosed: the Medication Generation Grows Up.  If you care about kids and meds, this is an excellent read, no sensational tone and she does a good job of giving a balanced presentation of the issues. 

We got an email from Stuart Kaplan, a child psychiatrist at Penn State, who's written a book called Your Child Does Not Have Bipolar Disorder.  I don't know Dr. Kaplan and I haven't read his book, but I wondered how he knows my child doesn't have bipolar disorder!  Check out his blog (linked to the book title) and let us know what you think.  I imagine that at least a few of the kids who are diagnosed with bipolar disorder might actually turn out to have it, but our readers know that I feel we need to re-think the bipolar diagnosis, especially with regard to the recommendation for lifelong treatment for those spectrum-y people.  I'm thinking that Dr. Kaplan and I may be on the same page. 

The New York Times has a ClinkShrink type article on Can You Call A 9 Year Old a Psychopath by Jennifer Kahn.  It's an interesting article, mostly because it doesn't have any real conclusions. She talks about children who lack empathy and are behavioral nightmares, and notes that half of these disaster children grow up to normal (meaning not psychopathic) adults-- including the father of the child who was featured.  She  reports on an intensive program to treat these children in an 8 week-long summer camp to teach empathy and modify behavior.  There's nothing about the article that indicates that the treatment is effective, though, granted it's all a research protocol and the stakes here are high.  The question is raised about labeling children as 'psychopaths,' a typically stigmatizing, untreatable, and damning diagnosis, and the case is made that the diagnosis would be useful if it led to interventions that prevented these children from becoming adult psychopaths (and perhaps criminals).  Personally, until there's a way to know who won't outgrow the problem, and an effective and accessible treatment to be offered, I'm voting "no" on labeling children as psychopaths.  I haven't been terribly impressed by the idea that childhood extrapolates to adulthood.  Won't every misbehaving teenager in foster care be given this label when there is no one around to recall that an angry/irritable/misbehaving teen was not lacking in empathy as a younger child?

Wednesday, May 09, 2012

Scenes from APA's Annual Meeting

Fortunately, I did remember that I was presenting on a panel on Tuesday afternoon, so I didn't leave until after our workshop!  We did a four-hour seminar on Sunday morning (Thank You to those who came out at 8 AM to hear us!), went straight to a book signing, and then Tuesday we did a new media workshop with Steve from Thought Broadcast and Dr. Bob.   It was a lot of fun and it was great to meet some or our blog commenters, including William, Synergysta, and Tigermom!  My one regret was that I didn't go to see Dianne Wiest, the actress who plays the psychiatrist on In Treatment

The protesters were their own story.  On Saturday, there were people with signs that said things like "Human Emotions aren't Diseases."  I tweeted out: "Is it a problem that I agree with most of the protesters?"  From what I could tell, they were calm and pleasant.  On Sunday, the crew was more aggressive.  They were chanting, "Stop Drugging and Shocking Our Children."  As we walked through this line of chanting protesters, thrusting pamphlets at us, one man followed us screaming.  My friend said she felt like she was walking into an abortion clinic.  On Monday I didn't see any protesters, but there was a giant jumbo-tron set up blaring out information about the DSM, interviews with people saying it wasn't scientific.  I only watched for a few moments, but I just thought, "yup."  The sign about the Psychiatry drugging our troops caught my attention because we hear so much in psychiatry about how their aren't enough psychiatrists to treat the troops and especially the returning vets.  While the suicide rates and use of psychotropics have both risen, their is nothing about the sign that indicates that the soldiers taking the medicines are the ones committing suicide, and I wondered how the troops feel about protesters picketing on their behalf. 


Some pics: The protesters of course.  One of Clink's slides as she explains "What is Twitter," the Hopkins Press sign from our booksigning (The duck is bigger than ever!),  Dr. Steven Hyman, former director of NIMH, giving a very thoughtful talk on the pros and cons of the DSM and his thoughts about the DSM-V.

Wednesday, May 02, 2012

Blame the DSM?

In the Washington Post, April 27, 2012, "Psychiatry's Bible, the DSM, is doing more Harm than Good," Paula J. Caplan writes:

About a year ago, a young mother called me, extremely distressed. She had become seriously sleep-deprived while working full-time and caring for her dying grandmother every night. When a crisis at her son’s day-care center forced her to scramble to find a new child-care arrangement, her heart started racing, prompting her to go to the emergency room.

After a quick assessment, the intake doctor declared that she had bipolar disorder, committed her to a psychiatric ward and started her on dangerous psychiatric medication. From my conversations with this woman, I’d say she was responding to severe exhaustion and alarm, not suffering from mental illness.

Caplan goes on to express her concerns with psychiatric diagnoses, the DSM, the problems with these labels that lead to the use of dangerous medications.  Oh, we've been here on Shrink Rap before, see "Diagnostic Labels That Change Lives". 

Caplan continues

In our increasingly psychiatrized world, the first course is often to classify anything but routine happiness as a mental disorder, assume it is based on a broken brain or a chemical imbalance, and prescribe drugs or hospitalization; even electroshock is still performed.

According to the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defines the criteria for doling out psychiatric labels, a patient can fall into a bipolar category after having just one “manic” episode lasting a week or less. Given what this patient was dealing with, it is not surprising that she was talking quickly, had racing thoughts, was easily distracted and was intensely focused on certain goals (i.e. caring for her family) — thus meeting the requisite four of the eight criteria for a bipolar diagnosis.
When a social worker in the psychiatric ward advised the patient to go on permanent disability, concluding that her bipolar disorder would make it too hard to work, the patient did as the expert suggested. She also took a neuroleptic drug, Seroquel, that the doctor said would fix her mental illness.

Caplan goes on to say that because of the existence of a psychiatric label-- one she contends is wrong-- the patient lost her friends, her marriage, her home, her self-confidence, her wealth, was forced to move across the country to somewhere she was isolated, and the six weeks she spent on medication (presumably Seroquel) left her with a condition that may someday leave her blind. 

Mental health professionals should use, and patients should insist on, what does work: not snap-judgment diagnoses, but instead listening to patients respectfully to understand their suffering — and help them find more natural ways of healing. Exercise, good nutrition, meditation and human connection are often more effective — and less risky — than drugs or electroshock.

Caplan, a Harvard psychologist, goes on to discuss a complaint she is helping to file against the DSM editors on behalf of 10 patients who were misdiagnosed. "Psychiatric diagnoses," she concludes, "are not scientific and they put people at risk."

Where do I even begin?  Please, please, I don't know the patient, I only know the presentation given, and I'm going to be very sarcastic, because the way it was presented struck me a ridiculous and it distracted from some valid points that might have been made if there wasn't the Evil, Idiot Psychiatrist Theme with a sensationalist tone.  Shame on the Washington Post for printing this.

Okay, so   I couldn't quite follow the case she presented, at first it sounds like the patient went to the ER with symptoms of a cardiac problem, or exhaustion, or a maybe a panic attack.  Perhaps, but some imbecile ER doc did a check list of symptoms, told her she had Bipolar disorder, and without even listening to her,  weighing other options, or taking into consideration the context of her life,  sent her off with Seroquel and a recommendation for  therapy.  This misdiagnosis then destroyed  her life, because  why would her husband and friends stick with her if she's got bipolar disorder?  What better time to leave your wife then when her grandmother is dying, she's stressed out and sick?  So she went to the ER because she was tired and her heart was racing.  I think they see this all the time...I think they do an EKG and perhaps make sure the patient isn't having a heart attack or arrhythmia, and if they think it's anxiety, the patient gets a dose of a benzodiazepine, and gets sent home.  Okay, but it's an ER and the docs are rushed and focused on what the patient needs now.  They make wrong diagnoses all the time, and it's not just psychiatry, and it's not just  because the doctor is sitting there with the DSM or has memorized the hundreds of possible diagnostic criteria.

Okay, but it turns out that she was on a psychiatric ward.  You can't get admitted to a psychiatric ward because you're tired, with racing thoughts, a fast heartbeat, talking fast and being distracted.  Pretty much, you need to be a danger--, suicidal, or having severe hallucinations or delusions, or be in extreme distress in some way.  This was a wealthy patient who could afford outpatient care.  All I'm sure of, is there is something more to the story. 

Finally, the patient was admitted to a psychiatry unit, so presumably there was a second doctor who met with the patient and a treatment team that observed her behavior for a few days.  Okay, I've stories of really lousy inpatient care, and I do believe the diagnosis could still be wrong and the treatment that was recommended might be wrong, or helpful at the moment but not necessary for the long-term, but I don't buy that a misdiagnosis let to the complete demise of this patient's life and a need to move across the country.  These are the types of problems one sees as a result of the behaviors a person might have because they have a mental illness, perhaps one such as bipolar disorder.

So I don't know the patient, or the diagnosis.  But I do know that the entire premise for this article is based on the idea that the patient was simply tired and stressed and perfectly normal and did not have a psychiatric disorder (the author tells us this) and this label alone destroyed her life.  The reader is not allowed to even entertain the idea that the patient had a psychiatric disorder-- that maybe the psychiatrist did get some history and make reasonable observations, and the patient really did have bipolar disorder? (Obviously, I don't know this).  There's no mention of a review of the records, discussion with family, interview of the doctor, Caplan is telling us her impression based on the patient's report only.   Maybe the patient had panic disorder, or a personality disorder, or even an adjustment disorder (perfectly possible given the stresses involved).  Oh, but then she took a bum recommendation to go on disability, and she got it!  I've seen really sick people not get disability.  It takes a lot of documentation and the government looks for ways to avoid paying this-- you don't get disability for having a psychiatric diagnosis, you have to be disabled by it.  So, somehow, this patient who  was simply exhausted and stressed, with No Psychiatric Disorder, per Dr. Caplan, managed to get admitted to a hospital and get disability benefits.

There were some valid points Caplan could have made.  The DSM is not a 'scientific manual.'  Personally, I don't find it terribly helpful in clinical practice.  I don't keep a copy in my office (I bought one to use while writing Shrink Rap), and I'm not planning to buy the DSM-V.  The overall concept is good, and it's very helpful to researchers to be certain that the groups they study have some diagnostic reliability, otherwise there is no way if knowing if a certain treatment addresses a specific group of people who can reliably be classified as having a specific illness.  This isn't all bad, but I don't need 370-400 diagnosis for my work (predicted in the new DSM-V).  And Caplan makes the statement that the editor, Allen Frances, says the work is based in science but has spread it's net too far.  If you read Dr. Frances' blog, you'll note that he is quite skeptical and opposed to many of the proposed changes for DSM-V.   It's not like the psychiatrists aren't thinking hard about these diagnostic categories and the ramifications they have.  Still, I'm skeptical about how we think about these disorders, especially Bipolar Disorder

I agree with Caplan that psychiatrists should listen more.  Fifteen-minute med checks have made a mockery of our profession.  I also tell all of my patients to exercise, eat healthy, and look for ways to solve their problems.  But to imply that these things are the answers for the majority of people who are suffering (and often too distressed, depressed, and unmotivated, to just pull up their bootstraps,  get up and exercise and cook a healthy meal )-- is an insult.  You know, sometimes those things really do work, but if people are able to do those things, they've often tried them before seeking psychiatric opinions.  To read Caplan's piece, you'd think everyone is an idiot.  And finally, ECT: it still in use because some people find it helps.

Okay, I am ranted out.  

Tuesday, May 01, 2012

APA 2012 Shrink Rap Feedback

I'm setting this space up a few days in advance as I finish up my slides for our APA presentations.  

If you come to hear any of speak, please visit here and let us know what you liked and what you didn't.  

For a list of when and where we will be talking, please go HERE.

Please note that not all of the sessions involve all of the Shrink Rappers.

Please let us know which session you attended, and feel free to tell us if there are topics you'd like to hear us speak on next year.

Slides from our seminar are here: