Monday, December 30, 2013

Depression, the Secret we Share -- A TED Talk by Andrew Solomon

If you've ever been depressed, if you've ever known anyone who has been depressed, if you've ever wondered what it's like to be depressed, or if you just want to listen to a wonderful talk,  do listen to Andrew Solomon's TED talk.

Sunday, December 29, 2013

Psychiatry Articles on the Web

There have been a number of articles I've wanted to mention lately.

In the New York Times:
When the Right To Bear Arms Includes the Mentally Ill

In the Wall Street Journal, set in our own Maryland:
For the Mentally Ill, Finding Care Grows Harder


Representative Tim Murphy Instroduces Mental Health Legislation

From the StarTribune:

Minnesota Security Hospital: Staff in Crisis Spreads Turmoil

In Atlantic Monthly, a poignant story about one man's battle with anxiety:

Surviving Anxiety

And finally, on Salon, it's from nearly two years ago, but I ran across Linda Gray Sexton's account of being suicidal and found it to be moving:

In the shadow of my mother's suicide

Friday, December 27, 2013

Assisted Outpatient Treatment?

Happy Holidays, everyone.  Blogging has been a little slow here at Shrink Rap as the Shrink Rappers overdose on cookies and get caught up in all the usual holiday stresses that get to everyone.
I've heard rumors that in the coming 2014 Legislative Session in Maryland a bill may be proposed to make Assisted Outpatient Treatment (AOT) part of the landscape.  As it stands now, we are one of the few states that does not have AOT, or forced treatment, for outpatients, outside of the forensic system for those on conditional release after having committed a crime (often a violent crime).

Since Maryland doesn't have AOT, I have no experience with it.  Perhaps it's a good idea; I don't believe it's humane to leave people living in the filth and cold on the streets if they have a psychotic illness that could be treated.  But I'm also well aware that treatment has side effects for some, and limited efficacy for others, and I worry that forcing people to get care in an already strained system is not the same as forcing them to get thoughtful, individualized care, with a spectrum of treatments being offered.  

So I'm staying out of the discussion at this point, as all I can say is that I don't know what the right thing is to do. I do know that people have strong opinions.  

If you live in a state with Assisted Outpatient Treatment, and you've been a part of the program, then I"d love to hear your comments.  If you have a family member who gets AOT, or are a doctor involved with such treatment, then I'd love to hear your opinion as.  If you've never personally been involved with forced outpatient care, even if you've been involved with forced hospitalization, then I'd like to ask you to hold your opinions for now.  I really  would like to hear from the direct recipients of these treatments.

Thanks so much!

Saturday, December 21, 2013

Cymbalta Goes Generic

On December 11th, the FDA approved the use of generic Cymbalta.  The generic version, Duloxetine, delayed release,  became available in the USA four days ago.

Generics generally work just fine and they cost less.  Now and again, some people have side effects or feel the generic is not as effective effective, and for those individuals, it makes sense to remain on the name brand medication.  Generics cost less and the active ingredients are the same.  Oh, but there was a little issue with the efficacy of one pharmaceutical company's preparation of Wellbutrin, XL, 300mg.  See the In The Pipeline discussion of the problem in this blog post, "The Generic Wellbutrin: Whose Fault is It?"

So, generic Cymbalta -- is it okay to take this today?  I have some thoughts.

 I imagine it's probably fine and it's probably cheaper.  In fact, I called one pharmacy, and their out-of-pocket price  for a single 30mg tablet ss $11.73 for Cymbalta, and $8.44 for generic Duloxetine.  So the cost is less, but we're still talking about a very expensive medication, even in generic form.   It's also the holiday season: stress runs high and moods run low.  I imagine it's fine, but for any given person, there is the question with any medication switch as to whether that person might be the person to have side effects or experience less efficacy.

So just to consider :
  --What happens to this person during an episode of depression?  If prior episodes of depression required hospitalization, it might be worth waiting a little and seeing how others who have had milder episodes of depression respond to the generic.
 -- Physicians won't be consulted first, the pharmacy simply makes the substitution.
 -- If there is a problem, the psychiatrist may be away for the holidays and a covering doctor may have to be consulted.
-- It's a preparation of the medication that US physicians have no experience with.  The generic form has been available in other countries.

Medications change to generic all the time, including many antidepressants.  The cost drops and the medication becomes more accessible.  Generics work fine, and I personally have no qualms about taking them.  So I'll leave this as my take away message: just beware that this change has occurred and prescribers may not know about it.  If patients call with problems, it may be worth asking if their medication was changed to a generic, and patients who have problems may want to mention to their doctors that the medication was changed. 


Tuesday, December 10, 2013

Who are the Mentally Ill? Please take my Brief Survey!

We hear about "the mentally ill" all of the time.  They shouldn't have guns.  They die an average of eight years younger than those without mental illness.  We don't have enough hospital beds for them.  They're filling our prisons and some of them are homeless... oh, the list goes on.

Defining the term is important because we single this group out for all types of discriminatory practices related to employment, driving, gun ownership, and even the ability to enter the United States for a vacation (at least on a few occasions).  We also single this group out for special benefits such as being allowed to take their dogs on airplanes or to receive benefits from the government in the form of disability payments,  health insurance in the form of Medicare, and entry into specialized day programs and vocational rehabilitation programs.  But there is no agreed upon definition of who is mentally ill, and the Diagnostic and Statistical Manual ( DSM) lists hundreds of disorders, limiting its utility as the determinant of who is mentally ill and therefore eligible for discrimination, stigmatization, or special benefits.

I'm a psychiatrist, and I confess, I have no idea who these "mentally ill" are.  I think if you asked many people in treatment about being mentally ill, they might think you are talking about someone else.  People may not think the term applies to them because they don't have the insight to realize they are sick.  Or, they may not think of themselves as mentally ill because with treatment, they've gotten better.  Finally, many people who get treatment don't identify themselves as mentally ill because they are too busy identifying themselves as being Mary's husband, Tom's mother, a doctor or a lawyer or a barber, master gardener, avid Raven's fan, or any other aspect of identity that consumes time, generates income, and adds value to society.   It might not occur to a patient to identify themselves as "the mentally ill" even if they take medicine and go to therapy. 

So I'm going to ask you.  Who are the mentally ill?  Please take my quiz only once, and please ask your social media followers to take the survey-- it should only take a few minutes.   It's am important question, one that guides all types of legislation and policies and I'd love to know what you think.  And thank you!  Comments on the post are welcome.


Sunday, December 08, 2013

Andrew Solomon on Shameful Profiling of the Mentally Ill by Immigration Officials

In Today's New York Times, Andrew Solomon, author of The Noonday Demon and Far From the Tree, has an opinion piece on "Shameful Profiling of the Mentally Ill."  It's on a topic that ClinkShrink has been very interested in: the disturbing issues that arise when the immigration department  ("ICE") decides the fate of psychiatric patients. 

I'll leave you to read Mr. Solomon's article about tourists who were not allowed to enter the United States because they had been hospitalized for depression in Canada.  One woman was simply traveling through the US to get to her cruise ship, stringed lights in hand to make her cabin festive.

Solomon concludes:

Stigmatizing the condition is bad; stigmatizing the treatment is even worse. People who have received help are much more likely to be in control of their demons than those who have not. Yet this incident will serve only to warn people against seeking treatment for mental illness. If we scare others off therapy lest it later be held against them, we are encouraging denial, medical noncompliance and subterfuge, thereby building not a healthier society but a sicker one.

Well put.  And have I mentioned that I loved Far From the Tree?  It's a wonderful look at issues of identity in those who are  different, but more than that, Solomon exposes the complexity of calling these conditions "disorders" requiring treatment, versus viewing them as a natural part of human diversity to be accepted rather than fixed.  The topics addressed include mental health disorders, but it's so much broader as he looks at topics including deafness, dwarfism, musical genius, autism, schizophrenia, transgender children, and children conceived in rape, to name just a few.  Ten years of writing, three hundred interviews, and well worth the read.   

Friday, December 06, 2013

Guest Blogger Dr. Erik Roskes with an Update on Gun Legislation and the Mentally Ill

In case you haven't heard enough from the Shrink Rappers on mental illness and gun legislation, I'm stealing a synopsis of the recent legislative changes from The Crime Report, a blog by forensic psychiatrist Dr. Erik Roskes.  Taken verbatim, with permission of course:
On October 1, 2013, Maryland’s modified firearms safety law took effect.  Passed in the aftermath of the Newtown massacre, this law expanded the group restricted from owning certain firearms.  This blog will focus only on the mental health aspects of the law, as I have no claim to expertise outside the mental health arena. 
 Editor's Note: See an official report from Connecticut State's Attorney on The Crime Report here.
Until September 30, 2013, two classes of people were restricted from possessing regulated firearms:
(1) a person who “suffers from a mental disorder… and has a history of violent behavior against the person or another,” and
(2) a person who “has been confined for more than 30 consecutive days to a [psychiatric] facility.” 
Effective October 1, 2013, a new law took effect, expanding and modifying the classes of people restricted from possessing weapons for reasons related to mental illness.  Now, the groups include:
(1) a person who “suffers from a mental disorder… and has a history of violent behavior against the person or another;”
(2) a person who “has been found incompetent to stand trial” (IST);
(3) a person who “has been found not criminally responsible” (NCR – this is Maryland’s version of the insanity defense);
(4) a person who “has been voluntarily admitted for more than 30 consecutive days to a [psychiatric] facility;”
(5) a person who “has been involuntarily committed to a facility” for any period of time; and
(6) a person who “is under the protection of a guardian appointed by a court…, except for cases in which the appointment of a guardian is solely a result of a physical disability.”
It is important to note the following:
Importantly, criminals without mental illness are only restricted if they have been convicted of specific “disqualifying crimes” or if they have received a 2 or more year term of imprisonment for a common law crime.  This disparity regarding removal of weapons from offenders with mental illness whose weapons would not be removed based on the crime alone raises potential disability rights questions.  
Thus, for example, category 1 requires no causal nexus between the individual’s mental illness and his or her history of violent behavior.  Thus, a person with, say, an eating disorder and a history of fighting during his or her adolescence would be subject to the restriction on firearm possession.  Conversely, the person with a history of multiple fights, no mental illness, and no other disqualifying events (such as a conviction for a violent crime) would be permitted to retain his (or, less commonly, her) weapons.  Where exactly is the logic here?
Categories 2 and 3 involve numerous defendants whose crimes themselves might not be dangerous.  In the hospital in which I work, the modal crime for which people are committed as IST is trespassing. 
While few people are found NCR for crimes that are not violent in some way, there are some whose underlying offenses are non-violent. 
Category 4 is especially concerning to those of us treating people with mental illness, in that it targets patients who seek treatment willingly, and who do not meet any of the other criteria for removal.  Thus, this restriction is imposed on people without any history of violence or criminal behavior, and who have sought treatment of their own accord.  Essentially the restriction punishes the very behavior we would wish to reinforce. 
Category 6 is interesting in its leading to bizarre rules, such as the recent report in Iowa regarding the ownership of guns by blind people.  From where I sit, this is simply a head-scratcher, making me wonder who is making decisions on our behalf. 
But most concerning for me is category 5, which was modified in the section of the code regulating involuntary commitment to require the hearing officer to determine if “the individual cannot safely possess a firearm based on credible evidence of dangerousness to others;” if the hearing officer so finds, he or she is to order the individual to surrender any firearms to law enforcement.  Note that no such finding is to be made for individuals civilly committed only due to self-directed dangerousness or suicidality.
According to the US Centers for Disease Control and Prevention, indicate there are over 19.000 firearm suicides per year in the US.  By comparison, there are about 11,000 firearm homicides each year. 
Based on research from the NIMH, at least 90% of those who commit suicide (approx. 17,000) have the sorts of mental illness that could lead to civil commitment.  Research varies with regard to homicide, but for discussion purposes, assume that as many as 10% (approx. 1100) of people who commit homicide by firearm have mental illness.  Simply put, for every gun-related homicide committed by a person with mental illness, there are approximately 17 gun-related suicides. 
If the new Maryland law were to be applied nationally, we would be potentially preventing a small number of people with mental illness from committing homicide by firearm, while doing nothing to protect the vastly larger number of people who might kill themselves with that same weapon. 
As I have already written, reactive gun laws do little more than assuage the public’s anxiety about mental illness, without doing much of anything to actually protect the public.  It makes us believe that our elected officials and appointed policy makers are doing something – anything – to make our communities safer, without regard for whether the things that they do actually will lead to positive results.  From where I sit, the changes in Maryland will do little to make our communities safer.  With apologies to a recent New York mayoral candidate, there are just too damn many guns. 

--Erik Roskes, M.D.

Wednesday, December 04, 2013

Guest Blogger Dr. Ronald Chase on Historical Misuses of Psychiatry

Dr. Ronald Chase is the author of  Schizophrenia: A Brother Finds Answers in Biological Science.   Today, he joins us as a guest blogger to talk about his recent trip to Heidelberg and the atrocities committed by the Nazis under the guise of psychiatry and a reminder for all of the things psychiatry should not be.  Dr. Chase is a biologist who taught neurobiology at McGill and now writes about mental illness.  As per the title of his book, the topic can be very personal.  

A Memorial is a Reminder

To research a book I am writing about the 19th century origins of modern psychiatry, I recently traveled to Heidelberg, Germany. I wanted to see the clinic where Emil Kraepelin and other influential psychiatrists had worked. I met up with Dr. Maike Rotzoll, a psychiatrist and historian who had been a psychiatric resident at the same clinic. She kindly agreed to show me around. As we approached the stately old clinic building, she suddenly turned from the beckoning entry and led me to a small enclosure just opposite. There, surrounded by a ring of small trees, stood a monument. “I want you to see this,” said Dr. Rotzoll.

It is a circular structure made of local sandstone and measuring about 10 feet in diameter. On its topside is an inscription which reads (in translation), “In memory of the victims — for us an admonition. We lament these 21 children, patients of the Psychiatric Clinic of the University of Heidelberg, killed in the name of criminal medical research in 1944.” All around the sides of the memorial are written the names of the murdered children. 

            Dr. Rotzoll explained that the children were killed by Nazis acting under the infamous Aktion T4 program of eugenics and euthanasia. Carl Schneider, then Director of the Psychiatric Clinic, was an active participant. Some contemporaries described Schneider as empathetic and enthusiastic about psychiatric rehabilitation, but he ordered these children killed to further the cause of what he called “National Therapy”. He collected their brains for histopathological research. Altogether, the Nazi euthanasia programs killed an estimated 200,000 persons with mental or physical handicaps, of whom 70,000 were psychiatric patients and 5,000 children.

            Although I learned a lot about late 19th century psychiatry while in Heidelberg, and I found the city beautiful, the thought of those 21 children weighs heavily on my memory. On the one hand, it is reassuring to know that post-war Germans are driven to express their horror and regret about what was done. On the other hand, it leads me to reflect on the dangers lurking even now for all of us. How was it that an institution that had hosted such distinguished psychiatrists as Franz Nissl, Emil Kraepelin, Alois Alzheimer, Karl Jaspers, and Hans Prinzhorn could have become involved in such terrible acts? Clearly, many medical professionals, among whom Carl Schneider, failed to see ethical implications in the prevailing social-political agenda, or their vision was blunted. It’s something to bear in mind as we read of American doctors assisting in the interrogation of prisoners detained as part of the war against terrorism. Especially worrisome is the recent report written by two psychiatrists detailing cases of complicity in the torture of prisoners at Guantanamo and other centers.

            I thank Maike Rotzoll for her contributions to this post.

Ronald Chase is an emeritus professor of biology at McGill University. His book combines, in alternating chapters, a 50-year memoir of his intellectually gifted older brother and an accessible explanation of the science related to schizophrenia.

Sunday, December 01, 2013

Quantifiable Goals

A local hospital was recently reviewed by one of those hospital accreditation agencies.  It did well-- passed with bells and whistles -- but for a few citations for psychiatry.

Individual Treatment Plans (ITP)s:
"Surveyors cited us for not having measurable goals in the ITPs. So, changes were made to [the electronic records system] to  clarify the requirement for objective and measurable patient goals as well as the patient’s progress toward those goals."

Okay, so help me with this.  Two decades of trying to come up with acceptable, measurable goals and I'm left with the idea that therapy has a limited number of goals and they aren't that measurable:
~Patient wants to feel better / Less psychic pain.
~To work and to love.
~No psychosis (and we measure that how?)
~To remain out of the hospital. (While measurable, I'm not sure that is acceptable to the bean counters).
~To remain out of jail/prison.
~Patient will resist urges to drink alcohol/shoot heroin/snort cocaine.
~Fewer self-injurious behaviors.
~Living up to potential.
~Acceptance of self as is, including the reality that patient may never be as beautiful/rich/smart or accomplished as he once believed he should  be.

What's measurable?  

Patient will have a Beck Depression Inventory score of less than 10 at every visit?
Patient will report spending less than 1 hour a day on compulsive checking?
Patient will lacerate himself fewer than 4 times per week and all lacerations will be less than 2 cm long and none will penetrate arteries?
Patient will report having suicidal thoughts less than 23% of waking hours?  

I remain clueless.  And of course, the treatment plan is about naming the goals, there are no citations for achieving them or not, or even for having them make sense in the context of the patient's life.

Paperwork chaos is not new.  I remember being an intern and being paged in the middle of the night to put a cause of death on a death certificate.  It was 3AM and I wrote down "pneumonia," because the patient had died of pneumonia.  I was paged again soon after.  "Pneumonia" is not an acceptable cause of death.  But that was what the patient died from.  I needed to know what organism caused the pneumonia, and that could only be known if a culture was done and that would take days to know.  The requirements said that a cause of death needed to be given now.  "Sepsis," I said (overwhelming infection).  Nope, I would still need to know the infectious agent, something I still didn't have access to at 3AM with a newly admitted patient.  I tried again: cardiopulmonary arrest.  That worked, sort of.  What was the cardiopulmonary arrest due to, I was asked?  Pneumonia, I said.  That's still not acceptable, unless I knew the organism.  I finally asked what is an acceptable cause of death.  I was given a few options, none of which pertained to the patient, but I picked one because there was nothing else to do.  

Okay, so what are acceptable, measurable goals in psychiatry?  And does measuring something make it more meaningful?   

Thursday, November 28, 2013

Happy Thanksgiving! Free Novels Now through Black Friday.

Happy Thanksgiving!

Now through Black Friday (November 27-29, 2013), three of my novels will be available as free downloads to Kindle. No cost.  No parking.  No crowds. 
 No Kindle, you say?  There is a link below to download a free Kindle app onto your computer, phone, or tablet. 

Double Billing is the story of a woman whose life changes when she discovers she has an identical twin she never knew existed. It's a short book and a quick read with some plot twists.  So far, I think it's my best fiction.

Home Inspection
is a story told through psychotherapy sessions in a format that is similar to the HBO series In Treatment.
Dr. Julius Strand is a psychiatrist who plods along in his already-lived life until two of his patients inspire him through their own struggles to find love.  

Mitch and Wendy : Lost in Adventure Land is  about two siblings who are struggling with their relationships in the aftermath of their parents' divorce. The story takes place on Wendy's 10th birthday when the kids get lost in an amusement park, only to learn they are being followed by a man who knows all about them from Mitch's misguided Facebook life.  Written for 4-5th graders, or the very young at heart.

If you don't own a Kindle reader, you can install a free Kindle app on your computer, tablet, or cell phone by going
here and then you can read any Kindle book, not just mine.

All three novels are also available as as paperbacks from Amazon (but not for free).

You can access each book by pressing on the title above, or you can get to all my books in all different formats with a single link to my Amazon page  here.

I'm more than happy to have people download my novels at no cost -- I'll be keeping the doctor day gig -- so please tell/tweet/blog/share the free promotions to anyone you think might be interested.

Finally, if you do read any of the books, please consider putting a review on Amazon.   

Thank you so much and enjoy the season.  I'll do this again in December for 2 days.  In the meantime, I may skip the mall this year.  Time to bake pies...

Sunday, November 24, 2013

The "Magic" of the Doctor-Patient Relationship

There is no doubt that in psychotherapy, some of what heals is the relationship the patient has with the therapist.  Medicines can be helpful, even when they are prescribed by a doctor with no personality, but no one enjoys going to see a doctor "just to get a prescription."  In therapy, it's hard, if not impossible, to heal if the patient does not see the therapist as being reasonably kind, empathic, and mutually valued, at least some of the time.   Aside from any medications, aside from the exact use of the words chosen, and aside from what tribe of psychotherapy the therapist aligns with, part of what heals is the relationship itself.  This we know.

But kindness, empathy, and interest are helpful in all doctor-patient relationships.
Psycritic has a charming post up called The Wizard: Psychopharmacology Magic.  Psycritic writes:

What most amazed me about The Wizard was his Zen-like serenity. Regardless of how much noise the patient was making or how many toys went flying around the room, he would be like the calm eye of the storm, holding still while everything else moved around him. His gaze was remarkable, intense yet warm and soft, like a bright candle. He would focus intently on whoever he was talking to, making that person feel important and special. His voice was smooth and soothing, almost soporific; perfect for those in emotional distress.
He took no notes during the appointments. His dictated progress notes were usually just a couple of paragraphs long, without pesky details like what medications the patient was taking and what medication changes were made during the visit. However, he did not have to remember those things. During the visit, he would shine his bright gaze upon the parents and say, "So tell me, what did we decide to do with the medications last time?" And the parents always provided the details. Maybe they knew that they would be quizzed this way, so they prepared so as to not be embarrassed. More likely, I think the parents were pleased that this eminent psychiatrist trusted them enough to empower them in this way.

Psycritic ends the discussion with: "However, I firmly believe that just being in his presence was one of the major therapeutic interventions that he provided for his patients and their parents."

It's not quite so lyrical, but over on KevinMD, Dr. Brian J. Secemsky, an internal medicine resident wise beyond his training,  also gives pointers on how to make your patients happy. He tells us:
1. Know your patients' names and interests and bring them up often.
2. Allow your patients to know something about you.
3. Communicate promptly, even if you have no answer.

Do those things, and in any field of medicine in our checklist era,  a doctor is  likely to be quite successful.

Let me add a few more pointers for good measure.   You can apply them to psychiatry/psychotherapy if you'd like, but they'll do for any field.

~Know the names of your patients' spouse, children, and pets, and ask about them.
~At the end of an initial evaluation, ask the patient how the appointment went for him/her.
~At the end of an initial psychiatric evaluation, or any medical appointment no matter how brief, leave a few moments to ask "What would you like to ask me?" (It's fine to admit you don't know the answer to a question).   
~Don't tell patients their problems are all in their heads.
~Don't tell patients in distress how others are worse off.  Patients already feel guilty for complaining or being unhappy.
~If a patient does not wish to follow your recommended course of treatment, explore the reasons why, respect them even if you don't agree, explain why you think it's important, and if the patient still does not consent, offer alternative forms of treatment. If there are none available, let the patient know that.
And finally:

What would you add to the list?

Virginia's Law On Civil Commitment: 4-6 Hours to find a bed or the dangerous go free

Virginia is a funny state.  They like their guns and they like their civil rights.  Well, not for sex offenders who get to serve life terms in "treatment" facilities after their prison terms are finished, but that's for another day.

If you've been paying attention to the news, you know that former Virginia state senator and gubernatorial  candidate Creigh Deeds was stabbed in the chest and face by his 24 year old son on Tuesday.  After the altercation, the son died of a gun shot wound, at this point his death was believed to be a suicide.  The son was a student at William and Mary College, one of Virginia's top institutions.  If that's not upsetting enough, it seems that the late Gus Deeds was brought to the Emergency Room  by police the day before for a psychiatric evaluation.  Virginia has a law that a bed must be located within  a few hours.  For some reason, possibly because no bed was available in that time frame, Gus Deeds was released.  It was a fatal mistake.  I'd also like to send you to Pete Earley blog post to read his take on the case: Deeds' Stabbing and Suicide Expose Bed Shortage But Will Anyone Care Tomorrow?

In What's Keeping People from Mental Health Help, Jennie Coughlin and Calvin Trice write in 

The process

Tucker said the VSCB looks to about 26 hospitals, as time allows, for patient placement when a psychiatric emergency occurs.
Once there is an emergency, a step-by-step process kicks in. Tucker said that a magistrate can issue an emergency custody order, or an ECO, if someone reports that a person is in crisis. The state of Virginia then requires that the person in crisis be able to talk to someone Tucker called a “pre-admission screener,” or pre-screener for short. The pre-screener comes from the local CSB.
He said that once an order is issued, the pre-screener has four hours to find an institution — with the possibility of a two-hour extension if needed.
“They’ve got to have a specific plan before the magistrate can act,” said David Deering, the executive director of the VCSB.
During that period, only the pre-screener has authority to stop the process.
If the pre-screener determines that the person meets the statutory requirements for commitment, then he or she must find a facility willing to take the person. The magistrate then can issue a temporary detaining order, or a TDO, allowing the person to be committed to the facility.
Once placed, patients may qualify for state payment of up to four days of treatment, if they have no third-party insurance.
The process is more difficult to execute than it used to be since there are fewer available beds, Deering said.
“The number of available site beds has been continuously going down across the commonwealth for year,” he said. “People are getting out of the business, because it’s a difficult and demanding business, and also the revenues to offset the costs are frequently not sufficient. That’s part of why you’re seeing a declining number of beds.”

So regardless of how dangerous someone is, there's a ticking clock to finding a bed somewhere in the state of Virginia.  What's amazing is that they do it most of the time (things have gotten faster since I last worked in an emergency room).  I believes this includes the transportation time from when the magistrate signs, the police find the patient, bring them to the ER, register them to the ER, get them seen, and locate a bed.  It's a lot to cram into 4-6 hours.

This policy is bad for several reasons: first off, many people brought by the police for psychiatric evaluations in our state are let go.  There may be one professional in the ER seeing patients, there may be many patients, there may be a situation that needs to be verified, consultation with other doctors to be had (in Maryland, two doctors must examine the patient to agree on commitment).  often spending a little time talking with the patient, bringing in family, setting up aftercare, letting drugs and alcohol wear off, clarifying if there was a real threat to begin with, getting medical clearance and labs back, a brain scan if needed, administering a medication --- these take a number of hours and sometimes (actually roughly half the time) enough bandaids are put on in the ER to make it safe to send someone home.  But if a time clock is running, there is no time for bandaids and the patient is more likely staying.  Which might not be bad, a 72 hour period to assess, clarify, treat, may be a good starting point and the inpatient unit can always opt to discharge sooner if that time isn't needed.  But more beds will get filled with a running time clock.

The other issue is that there aren't enough beds, so people who may well be dangerous are sometimes let go.  Tragically, this did not go well for the Deeds family.  

I had never heard of the 4-6 hour beat the clock to make a medical decision.  Do they have to do that with medical or surgical patients?   I know, I know, they are all there voluntarily, but actually, that may not be the case if they are refusing care and bleeding to death, or need care but wish to flee an accusation of a crime, came in while unconscious, or are objecting to life-saving care because of the money.  Even med/surg patients may end up being held for hours longer than they'd like.

And to Je Suis, note that Viriginia pays for 4 days of involuntary treatment.  

Okay, if you haven't please already, please do check out Pete Earley's article.

Saturday, November 23, 2013

So You Want to be a Psychoanalyst?

I'm not a psychoanalyst and I've never been in analysis.  However, our blogger world friend, PsychPractice, is a psychoanalyst in New York, and she has a post up on what becoming a psychoanalyst entails.  I think the final answer is an enormous amount of time and money.  See her blog post, "The Couch, First Session."

PsychPractice writes:

I interviewed with 2 different analysts, 2 times each. I don't remember for sure, but I think each of the 4 interviews lasted at least an hour, maybe 90 minutes. Or it might have just felt that long. The first interview with each analyst was a get-to-know-me session. The second involved more getting to know me, following up on things I spoke about the first time around. And I also had to present a case, which seems like it would be the hardest part, but it wasn't. It was the easiest.
I bought two suits. I wore one to the first interview with Dr. G, and the other to the first interview with Dr. E. Then I had them dry-cleaned, and I switched off for the second interviews. I also prepared two different therapy cases, each of which reflected certain challenges, and the ways in which I work with patients, and my ability to think analytically.

I had a lot of internal debate about how I wanted to come across. Specifically, just how neurotic did I want to appear. Too much, and they'd think I was unstable. Too little, and they'd know I was lying. I had an intuitive sense that I was about the right amount of neurotic for this kind of training-you don't train to be an analyst if you're not at least a little screwed up-but I wanted to make sure to seem like it.

I discovered pretty quickly that how I wanted to seem was irrelevant. And that discovery made me want to do psychoanalytic training all the more. Because the people I interviewed with did not shy away from asking difficult questions about my family, my motivations, my conflicts. And they did not settle for pat answers. And they pursued important topics. And they did so with kindness and without judgement. And I realized that I wanted to be able to do what they were doing.

Wow, PsychPractice has her suits dry cleaned each time she wears them?!  Does everyone else do that?  Even if nothing gets spilled on them? 

 All kidding aside, I found her post to be interesting and enlightening. 

Wednesday, November 20, 2013

Now It's the Cardiologists' Turn

People like to rag on psychiatry: we've got our own anti-psychiatry movement, and one of the biggest issues for these groups is that "psychiatry" (whoever our singular voice might be) misrepresented itself by saying there are chemical imbalances responsible for mental illness, when no precise imbalance has yet been identified.  We're not like internal medicine and it's sub-specialties where there are numbers and a cut-off for when you have diabetes, and when your cholesterol raises your risk of heart disease.  Those numbers are reportedly precise science, but, actually, those illnesses are defined like psychiatric disorders: by consensus of a bunch of people on a committee. 

These days I follow the cardiology news with interest.  Today is the 6 month anniversary of my brother's death from coronary artery disease.  My brother did not know that his coronary arteries were quietly calcifying and by the cardiology predictors, he had no reason to believe he was at any imminent risk of death.  While he once had an elevated cholesterol level, he did what doctors recommend: he changed his eating habits, increased his exercise, and he died with wonderful numbers.  Never a smoker, the one clue that this might have happened was that our father also died of heart disease he didn't know he had, at a very young age.

For a field where things are supposed to be so much more clear cut than psychiatry, cardiology also has it's camps.  There are those who prescribe statins at a very low threshold, and those who feel they are over-prescribed.  Does this sound familiar?   In yesterday's LA Times, there was an article titled Cardiologists Cast Doubt on New Statin Recommendations, while USAToday's article notes Heart Experts Debate Who Should Take StatinsAnd if you'd like a more medical take on this JAMA has "dueling" viewpoints on whether healthy men should take statins HERE and HERE
I guess JAMA doesn't care about cardiac prevention in healthy women?

In psychiatry, we usually get second chances.  In cardiology the camps are frequently life-or-death and 1/3 of people will die during their first heart attack.  In psychiatry, we're nebulous about prognosis.  In cardiology, there are definitive treatments (such as bypass surgery), though cardiac stents are not free of their own angst these days.   Obviously, I now wish my brother had taken a statin and I wish he'd had a calcium score done so he would have known he needed more aggressive intervention.  With the statin's all-too-well publicized side effects, and his successful efforts to modify "risk," it's easier to look back and say what might have been.

In the meantime, the issue in cardiology is about risk, and they do have non-invasive (albeit expensive) ways of getting definitive answers about who does or does not have coronary artery disease.  I'm left to wonder why more at-risk individuals aren't encouraged to undergo such imaging given that the technology is available.

So let me ask this: if an expensive MRI would give you a definitive answer on whether a patient with a psychiatric disorder would respond to a medication, would you order that test?  Pretend the test costs a great deal of money (let's say $5,000), but the treatment is cheap (let's say $10/month)?  If you're the patient, would you pay for the test, or try the cheap medication first, knowing the medication has some risks?  What if you had no symptoms, but were told that a screening test would enable you to stop the progression of a life-changing illness?  What if there was a cheaper version (say $2000) but that entailed radiation while the more expensive test did not? 

Tuesday, November 19, 2013

Turning the heat on ICE

Today's blog post can be found over on Clinical Psychiatry News HERE
where ClinkShrink is talking about the fate of mentally ill immigrants who are detained without either legal representation or psychiatric treatment.   

Clink also tells us what to do if an illegal immigrant is admitted to your inpatient unit and  ICE comes knocking at your door.  

ICE: Immigration Customs Enforcement. 

Sunday, November 17, 2013

Is Video Game Addiction for Real?

For the moment, it appears that I'm an "expert" on Internet addiction to video games:  Candy Crush and Angry Birds in particular.  I had a great time as a guest on Antonio Mora's show Consider This on Friday night, when I was interviewed with Time Magazine reporter Eliana Docterman.  We were the final segment, a lighter-side close to the 10 pm news, and it aired around 10:50 pm.  A driver came to pick me up, someone was at the studio to do hair and makeup, a studio man to rig me up to a microphone and earpiece, and there were  a half-dozen calls with producers in New York to discuss what topics I was and wasn't able to discuss, plus a few calls for "Is the driver there? Are you on your way? Are you at the studio? 5 more minutes, 2 more minutes..." I'm sure it would have been even more fun if I'd been on the set in New York, but it was pretty good from the remote studio in Baltimore, even with my stage fright.

 I felt like a celebrity for an hour there, and I felt like I could discuss the topic, but I did not feel like an expert on internet addiction.  What really helped was when the producer told me that the host thought he was addicted to a phone game (brickbuilder) -- I said he should mention that and it would be a great springboard for discussing what makes something an addiction. When the show finished airing, Antonio said to me, "You know, I do think I was addicted. I played it all the time, in the elevator, every chance I got."  I asked him how he finally quit and he told me that his Blackberry was upgraded to a new model and he would have had to carry an old Blackberry just to play.  Plus, he had mastered the game and it was no longer challenging.  An addiction?  That's like an alcoholic saying they stopped drinking because the liquor store next door closed and it was too much effort to drive to the one down the street.

I'll say what I said on the show: according to the APA, the jury is still out on whether internet gaming is an "addiction" --- it's been placed in a category under conditions warranting further research and experience.  We banter the term "addiction" about freely, as a joke, and so when 35% of gamers polled say they are "addicted" we don't know what that means.  In studies of young Asian males, there is some evidence that those with problems with gaming have pathways in the brain that light up in similar patterns to those addicted to drugs (or so says the APA).

Often, people play phone games because they are fun!  It's a form of entertainment, and some people  have trouble stopping when they are doing fun things.  That doesn't make it an illness or a disorder.  Something is a problem when it's a problem.  That's what I said on TV, I may have said other things as well.

 Behavioral addictions, such as Candy Crush, do not have the obvious biological underpinnings of an addiction to alcohol or narcotics or other drugs where there are physical signs which accompany the withdrawal of a substance the body is dependent upon -- changes in heart rate, sweating, diarrhea, elevated body temperature, or even seizures.  But we've come to include other, non-biological areas of dyscontrol as addictions -- such as gambling -- so why not video games?  It may be hard to figure out who can't stop and who won't stop.  In terms of problems, these games are often not a "problem" for the players, but for the people around them.  Teenage boys in particular like to play video games for hours on end, and their parents may be troubled by this -- if the teen stops other activities to play, such as going to school, getting acceptable grades, or making expected progress towards life goals, then it may well be a problem worthy of attention, whether that attention entails removing the game from the phone, or removing the phone from the kid, or seeing a therapist....well, I'll stop there.

I'm not much for DSM criteria.  If you have a behavior you can't control and it's interfering with your ability to live a productive or healthy life, then get help.  Throwing a disorder into the DSM seems to do a few things: first, it gives the problem some credibility so insurers will pay for it's treatment (a good thing), and second, it relieves part of the responsibility of the individual to control that behavior (maybe, sort of) because they have a 'disorder,' and that may not be a good thing.  It may call attention to a problem so that people will know there is help available, but we don't want everyone who deviates from the norm to be labeled as disordered. 
If your a normal-weight person who is addicted to chocolate, and 'has to have a candy bar every night' but is otherwise well nourished, then enjoy your candy bar, call it an addiction if you like for fun, but it's not a disorder.

If you think you're addicted to Candy Crush, here are a few things to ask yourself.  Are you missing work or deadlines at work because you are playing, in such a way that it has focused some negative consequence upon you -- such as being fired, a demotion, a write-up, the loss of grant because you didn't get the proposal in on time, or the wrath of your boss?  Is your partner more then momentarily annoyed because playing has interfered with your activities in the relationship or around the home?  If you've been divorced only because you've given your life to Candy Crush, you have a problem.  Do you enjoy it?  If you're playing a game that doesn't give you pleasure, rethink this.  And if you decided you do have a problem, remember you can always delete the App.   

Saturday, November 16, 2013

PTSD and the Forensic Psychiatrist

This blog post is aimed at anyone considering a career in forensic psychiatry. Please read this interview in the Ottawa Citizen entitled 'Tough forensic guy' John Bradford opens up about his PTSD'.

I'm going to preface this post by saying that I know the man featured in this interview. He is an extremely accomplished and internationally recognized authority on the evaluation and treatment of sex offenders. To think that we could have lost him is a devastating idea to me. He has always been respected within the forensic community, but I respect him even more after this interview.

In this article Dr. Bradford talks about the recent stress a pretrial evaluation placed upon him when he had to work overtime, under a deadline, to evaluate a sexually sadistic murderer. He was required to watch actual videos of the crimes, to witness the killings and to hear the pleas of the women he knew were doomed. The experience brought back recollections of other serious crimes and cases he had been involved with in the past. In the interview he discusses the effects this had upon him over time and the challenges he faced when he finally needed to get help dealing with it. Getting treatment was particularly difficult for him, both because of his prominence but also because forensic psychiatrists are just supposed to be able to handle this stuff. In his own words:
“It’s complicated,” he says. “In my case it was macho. I’m a top forensic psychiatrist and I saw it as a weakness. I don’t talk about the treatment much because it’s difficult for me but getting to it early is important.”
I understand completely what Dr. Bradford is talking about here. Over the years, forensic psychiatrists end up hearing and seeing information about crimes that are pretty terrible. We see digital photographs of crime scenes, autopsy photographs, surveillance videos of murders, suspect interrogations, phone call tapes, written letters and other pieces of evidence that relate detailed information about violent crimes. A single case can require weeks and hundreds of hours of study with repeated exposure to horrible events.

Even without developing PTSD this can change your view of the world a bit. At times I joke that when I give directions now I don't use street names anymore, I give directions in terms of crime scenes: "Take a left and drive south a few blocks until you get to the church that was the scene of the ice pick murder, then take a right until you get to the samurai sword decapitation..."

Yeah, it makes life a little weird.

There are prohibitions about talking about active cases, for legal reasons, but there are also good clinical reasons why you don't talk about your cases with friends and family. Once you get these images in your head they don't go away, and it's not fair to place them into the heads of other people. I warn my program applicants about this too.

To a certain extent, medical training weeds out people who aren't able to handle this. I think there's a reason why my medical school put anatomy class as the first class on the training agenda. After four months hanging over a formaldehyde soaked body, it took me a while before I could eat chicken again. The muscle fibers and tendons just didn't look the same after anatomy class.

Some people complete forensic training and never touch a forensic case again and never do forensic work. I've often wondered about that, and wondered what we could do ahead of time to help people decide if they're really cut out for the work. Given Dr. Bradford's interview, we should probably also think about what we should be doing to look after the people who stay in the work.

Friday, November 15, 2013

Candy Crush: Psychiatry's New Frontier? Watch Dinah on Al Jazeera America Tonight at 10:45 PM Eastern Time

It started innocently enough: a conversation with an old high school friend about Angry Birds.  Joe warned me, "Don't do it. It's like crack."  Soon, I was hooked, and I wrote a blog post called A Brief Psychological Analysis of Angry Birds.  It got picked up by KevinMD and a legal blog.  It got a lot of Facebook 'likes,' more than any for my profound psychiatry writings.  Isn't that silly?

Last week, I was contacted by Eliana Docterman, a reporter at Time Magazine.  I know about Angry Birds, could I comment on Candy Crush, it's taking the country by storm, millions of downloads with people spending a lot of money while they abandon their lives to cuddle with their phones.  Candy Crush?  I'd never heard of Candy Crush.  I downloaded the app and started to play, and I spoke with Eliana and gave her my "professional" opinion of why this game was appealing.  I say "professional" because video games are not my area of expertise.  I made it to Level 23, by the way, before I got stuck for 2 days and deleted the app from my phone (--one way of dealing with an "addiction").  

Eliana's article Candy Crush: The Science Behind Our Addiction appeared online this morning, and my phone started ringing.  Would I be on the radio? Would I be on TV?  I called ClinkShrink -- is this too silly?  We're psychiatrists, we can speculate, like everyone else, about video games, but really this isn't what people come to us for.   Clink declared it "Goofy."  I prefer the terms 'silly,' 'light-hearted,' or in this case 'sweet.'

So tune in to Consider This on Al Jezeera America tonight at 10:45 PM Eastern Time and I will be on with Time Magazine reporter Eliana Docterman and host, Antonio Mora.  It's filming live, so let's hope I can stay awake that late -- I may be trying for a sugar high at that hour.  Perhaps a little candy?  

Life Sentences for First-time, Non-Violent Offenders

I'm hijacking Shrink Rap for a moment.  I feel like I'm justified in linking to an article about mandatory minimum prison terms because the correctional system is where many people obtain psychiatric services in our country. 

Nicholas Kristof writes in Serving Life for This?
about some egregious stories of people serving long prison terms for drug-related offenses.  

One woman had no prior legal history, was not found with any drugs, but was convicted based on the testimony of others who testified against her in exchange for reductions in their own sentences.  So the 32 year old mother, with no prior arrests, was sentenced to life in prison, not because the judge thought that was fair, but because minimum sentencing laws left him no choice.  Mr. Kristof has other stories, including one of a man who transported meth to pay for his son's bone marrow transplant, after a community fundraiser brought in $50,000 falling quite short of cost of the procedure.

It's time to end the minimum sentence experiment for non-violent crimes.  If you don't care about the lives of those lost to prison, about the effects this has on them or their families, then care about those of us who pay taxes.  A person in prison is supported by the government: they get free housing, food, clothes, heat, medical care -- all at the expense of the taxpayer.  It's not cheap. People in prison don't work, they don't earn money, they don't pay taxes -- it's a lose-lose proposition every way you consider it, and it hasn't worked in our so-call "War on Drugs."   Long sentences?  As a mandated minimum with no consideration of the circumstances?  For a non-violent crime?  It's time to reconsider these laws and question whether they make sense or should be repealed. 

Thursday, November 14, 2013

Allie Brosh of Hyperbole and a Half on NPR's Fresh Air!

If you've ever read Allie Brosh's blog, Hyperbole and a Half, you wouldn't be surprised to learn she wrote a book.  It's called Hyperbole and a Half.  Allie (pictured above), likes to write about and illustrate her life.  She talks about her childhood adventures (to use a tame word), her hopes, dreams, and aspirations, and her struggles with depression.  The drawings and the humor are phenomenal. 

So yesterday, I'm sitting with a patient and my phone lights up.  I ignore it.  Between patients, I read.  An excited text from Jesse.  Jesse if often excited; he'll be excited that he's in this post, in fact.  "Allie Brosh of the Hyperbole and a Half blog is on NPR.  On Fresh Air."  Jesse never texts-- usually he emails, rarely he calls.  This was a text.  That's was just one clue that he was excited.  After the next patient, I checked my email.  There was an email from Jesse.  Allie Brosh was on Fresh Air, here is the link to the show.  He reminded me that when she'd stopped blogging for a while, her readers had gotten very concerned (thousands of them) and then she returned with an account of how severely depressed she'd been.  I remembered that. 

I listened to the NPR interview.    I learned some things.
~The yellow triangle is a pony tail.
~Allie tried to be a runner for her first career out of college and she was initially successful, sometimes winning pumpkins, until she hurt her Achilles tendon.
~Hearing her read her blog posts, they are interesting, but if you hear it on the radio without her pictures, it loses something.
~Allie talks very poignantly about her struggles with depression.  Her descriptions of her emotional state are well worth listening to. Go for it. 
~Psychiatry helped her (always nice to hear).  
~She first saw a psychiatrist at the age of 3 after biting her sister then setting her on fire.  
~Allie likes dogs.  A lot. 

Is the Emotional Support Duck Biting Back?

If you've been following Shrink Rap since the very beginning, you'll know that our adoption of the Duck as our mascot was prompted by an article in the New York Times, back in May of 2006, about people taking emotional support animals on airplanes for comfort. Mostly, people brought dogs, sometimes cats, but also monkeys, a miniature horse, and someone had brought a duck dressed in clothes.  The three of us embraced the concept of a well-dressed emotional support duck, and the duck idea ran wild, though we eventually settled with a traditional, naked, yellow rubber duck.  

Two years ago, we summarized the history of the rubber duck here
We've probably taken the concept too far, as we spent a Saturday night at APA with necklaces of rubber ducks around our necks, a duck cake to celebrate the anniversary of our blog, and I have ducks hanging from my kitchen chandelier.  A reader (Lily, where did Lily go?) contributed to Heifer international in our honor: a flock of ducks to a family of course.  And when our book went to press, there was a meeting at the Johns Hopkins University Press to consider whether they were willing to put a small duck on the cover of our book-- told we'd look like quacks, The Duck was Nixed. It's been a ducky history here at Shrink Rap and somehow we've stayed away from blogging about Duck Dynasty.

So I would be remiss if I didn't point you to an article in the New York Times talking about a backlash to the concept of emotional support animals on planes.    In an article titled Emotional Support with Fur Draws Complaints.,  Billy Witz writes:

Classifying animals as emotional support animals has long been permitted under antidiscrimination laws, allowing owners to take them into restaurants and shops or to residential buildings that have no-pet policies. To demonstrate the need for an emotional support animal, the animal’s owner needs a letter from a mental health professional. 

But their presence on airplanes is increasingly facing a backlash from flight attendants, passengers with allergies and owners of service animals, like Seeing Eye dogs, who say that airplane cabins have become crowded with uncaged animals who have no business being there. The Department of Transportation does not require airlines to keep data on emotional support animals. One that does, JetBlue expects more than 20,000 emotional support and service animals this year. 

I would like to point out that the  complaints are about emotional support animals with fur, not feathers, and perhaps there should be more of a push for emotional support ducks.  I haven't heard that they are bothering anyone, and they are very tasty as well. 

Wednesday, November 13, 2013

On Giving Gifts to Patients: Where's Your Line?

There is an interesting article in the New York Times by Abigail Zuger called When Healers Get Too Friendly.  The author talks about giving a patient her old laptop, stripped clean, with no other useful destination but the back of a closet, and most likely, ultimately the trash. Dr. Zuger writes:

And now it is suddenly decades later, his H.I.V. has long been perfectly controlled, and he is still fomenting revolution. He used to march and holler; now he works social media with a miserable old desktop computer that keeps breaking down.
As it happens, about a week before one of our infrequent appointments — he barely needs me any more — I had treated myself to a brand new laptop, sending an old perfectly good model into the back of the closet.

Of course I wiped its hard drive clean and gave it to him — for he is my old friend. But (also of course) we met furtively in a back corridor and I carefully concealed the contraband in a nest of old grocery bags — for he is my patient, and gifts to patients …well, we don’t usually do that.

Once again, apparently, we were dealing with two incompatible positions. Everyone knows that professional boundaries guide all medical activity in hospital, office and clinic. But aside from indisputable sexual and financial depredations, no one agrees exactly where these boundaries lie.

She goes on to write about a physician who was reprimanded for violating boundaries:

The incident that it set it off: Dr. Schiff (now 63, an experienced senior clinician) had tangled with an insurer on the phone for two hours before he gave up and handed an impoverished patient $30 to pay for her pain pills. A resident observed the transaction and turned him in. But Dr. Schiff is a proud repeat offender, whose past infractions include helping patients get jobs, giving them jobs himself, offering them rides home, extending the occasional dinner invitation and, yes, once handing over a computer.

He was told physicians should stay away from “random acts of kindness” — an activity that may sound harmless but is quite distinct from the practice of medicine, and has its risks. Patients might get too familiar, expect too much.  

You can read Dr. Schiff's response here -- well worth it.

Oh, my, we're all in this world together as sometimes wretched human beings trying to eek through the pea soup of life.  Isn't it nice if Dr. Zuger's trash can help someone's life be a bit more comfortable,  pleasant, or productive?  Isn't being a doctor about being kind to others or do we need to confine it to whichever activities are randomly designated as "healing"?  

With psychiatry, it gets stickier, because we care about the meaning the transactions have with out patients and how our actions can be interpreted and misinterpreted.  Still, I like being helpful to people and the line is not clear.  For me, there are a couple of lines here that are very clear: I would never give a patient cash.  I think money is too loaded a subject, and as the doctor writing pointed out, she once gave a patient $20 and the patient, who needed care, did not come back for a very long time because she was waiting to be able to repay the doctor.  But I don't give cash to anyone but charities (--except as holiday/birthday gifts to select individuals) because the issues of how it might effect a relationship are so complicated.  This is why people give gift cards (which  limit the giftee's spending options) or a pay a premium to give an American Express gift card (which is paying a fee to essentially give cash).  And I don't transport patients, because I'm not comfortable doing that.

But where's the precise boundary?  I'll hunt for samples for an uninsured patient.  When my computer works, I may download a form and sign off on someone's need for a handicap parking permit, even though it's not for a psychiatric reason -- but I like to be a nice person and it saves someone a trip to their doctor with the mobility issues and expense, and if they've been talking about it and just not getting there, I like being helpful.  I don't prescribe pain meds, at all, ever, but they can't be called in and I once wrote for a few for a cancer patient whose oncologist was an hour drive away.  If it's cold and I'm making myself a cup of tea, I may put one out for my next patient.  I often suggest articles or books I saw that a patient might enjoy, and I once emailed along a job listing -- nothing bad happened from that but the patient didn't apply for the job and I decided I shouldn't do that anymore because I don't want to be one more person he disappoints by not getting a job.  I've recommended other doctors in other specialties and other psychiatrists (Jesse! being one) for relatives of patients, and I've asked people I know with medical problems about their experiences and shared them with my patients.  I wish I could serve homemade cookies at the holidays.  Another psychiatrist once asked me what I thought of his hiring a patient who wanted the job as his assistant and I said, "You can't hire your patient."  In psychiatry, that seems obvious, if for no other reason than the relationships would conflict and one patient would have access to another's information and that seems wrong.  It turned out the other doc wasn't really asking because he was considering this, but he wanted to say to the patient "I consulted a colleague and who said this is unacceptable."  

Don't sleep with or kill your patients.  That's pretty clear. 

Where's your line?  What have you done, or not done, for a patient?  What has your psychiatrist done for you and how did you feel about it?  What do you wish they'd do for you?