Saturday, July 26, 2014

Of Guns and Ducks

Around the web, I thought I'd point out some interesting stories:

A federal court upheld the legality of a Florida law which forbids doctors to discuss gun ownership with patients. The law, passed in 2011, was challenged as being a violation of a doctor's right to free speech.  Apparently, the second amendment is more important than the first amendment.  Why stop at gun ownership, perhaps every aspect of medical care should be legislated?  What right does my doctor have to pester me about whether I smoke or how much I drink or whether or not I'm getting enough calcium?  From the StarTribune:
The ruling by the 11th U.S. Circuit Court of Appeals in Atlanta overturned a previous decision that had declared the law unconstitutional. An injunction blocking enforcement of the law is still in effect, however.
The 2011 law, which had become popularly known as "Docs vs. Glocks," was challenged by organizations representing 11,000 state health providers, including the Florida chapters of the American Academy of Pediatrics and the American Academy of Family Physicians
Doctors who break the law could potentially be fined and lose their licenses.

The issue of boundaries in psychiatry is always a sticky one, and there are times when it seems prudent to bend some of the usual boundaries by a bit.  Still, I tell students, readers, anyone who asks me, that the two rules one should never violate: Don't sleep with or kill you patients.  Hmmm, this is a tragic story, but as the media is reporting it, a psychiatrist in a Philadelphia suburb pulled out his own gun and fired on a patient who had already shot at him and had killed his case manager.  Read the NY Times account Here.  The details are still unwinding.

And on to ducks:

Iraq veteran Darin Welker, pictured above, suffers from pain, depression, and post-traumatic stress, and he has found comfort from his 14 emotional support ducks.  Farm animals, however, are not legal in his Ohio town, and there is a hearing to force Welker to get rid of the ducks!  We at Shrink Rap say NO!  Let the vet keep his support ducks! So long as he does so in a way that does not disturb others or does not endanger the ducks, we're on his side.  And apparently the same town allows one therapy pot-belly pig per family, so why not some ducks?  Link to the article is Here and there is a video of Welker with his ducks.

Finally, over on Clinical Psychiatry News, I responded to a reader's comment that the term "shrink" is odd and offensive.  After eight plus years, I think we're moving on as the Shrink Rappers, though I am sorry it offends someone.  What do you think?  Read:  The Stigma of Being a Shrink.

I'm going to try allowing comments again. I miss everyone's input, but I will be moderating for now.

Wednesday, July 23, 2014

Stanley Family Foundation gives $650 million for Psychiatric Research

From the New York Times, In Spark for a Stagnant Search, Carl Zimmer and Benedict Carey write:

Late on Monday, the Broad Institute, a biomedical research center, announced a $650 million donation for psychiatric research from the Stanley Family Foundation — one of the largest private gifts ever for scientific research.

It comes at a time when basic research into mental illness is sputtering, and many drug makers have all but abandoned the search for new treatments.

Despite decades of costly research, experts have learned virtually nothing about the causes of psychiatric disorders and have developed no truly novel drug treatments in more than a quarter century.

Broad Institute officials hope that Mr. Stanley’s donation will change that, and they timed their announcement to coincide with the publication of the largest analysis to date on the genetics of schizophrenia.

Let me also encourage you to listen to the podcast linked to this article.


Sunday, July 20, 2014

Does Anti-psychotic Withdrawal Make People Kill?

So here's an interesting article in the Irish Times: Niamh O'Donoghue writes in "Murderer accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court."  I'll let you surf over there if you want to read more, the title says enough for me.

My first thought was :  Really?  People stop their medications all the time, cold turkey, without doctor supervision or approval, and they don't generally kill people.  So how do you know if someone's "symptoms" --like agitation -- are he result of medication withdrawal, or the result of a recurrence of the original illness that the medication was treating?  There's not a great way to sort that one out, but I was befuddled by the idea that one would attribute murder to medication withdrawal.  Maybe that should be on the TV commercials with the list of side effects, "Stopping this medication suddenly can lead you to kill people." 

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at:

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at:

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at:

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at:

Wednesday, July 09, 2014

Shrink Notes: what does your doc think of you?

I've written before about shrink notes back in 2011.  See Here and Here.
With the increasing transparency we're seeing with electronic records, there are now systems that allow patients to access their doctor's notes.  The first time one of my patients did this, he casually mentioned that the record included the wrong dose of a medication, and I suggested my patient might want to tell his doctor about this.  

In psychiatry, we've been a bit touchy about this.  Patients might be distressed to see what we write about them, they may see some of the terms we use to describe them (like delusional?) as being negative.  

The New York Times has an article discussing a pilot study in Boston to give patients electronic access to their therapists' notes.  In What the therapist thinks of you, Jan Hoffman writes: 

The pilot project has raised questions in the mental health community. Which patients will benefit and which might be harmed? How will the notes alter a therapeutic relationship built on face-to-face exchanges? What will be the impact on confidentiality and privacy?
And the project presents difficult choices for those who argue for parity between medical and mental health patients. Should patients with schizophrenia, for example, who may stop taking their medication after reading that they are doing well, have the same access to treatment notes as those with irritable bowel syndrome?
But the lingering underlying question is, do patients really want to know what their therapists think? Dr. Kenneth Duckworth, who is the medical director of the National Alliance on Mental Illness, an advocacy group, said: “I’ve offered to share my notes with patients and they’ll say, ‘No, I’m good.’ But it’s a good concept that should be researched.”

The article goes on to describe the content of some therapist's notes and the impact it has on patients to read it:

He clicked open another therapy note.
Mr. Baldwin “is continuing to try to push himself to get out more and to be more socially connected even while his emotions tell him to do the opposite,” Mr. O’Neill wrote, adding that his patient is “clearly making good, and even courageous, efforts on a number of fronts.”
Mr. Baldwin, who celebrated his birthday recently with a museum lecture, movie and dinner, flushed with pride.

Hmm, I thought.  These are the type of interpretations I made aloud to the patients, they aren't the stuff of my notes, and if they were, I'd be living in the office trying to write accurate process notes of sessions.  A lot goes on in a session, and notes of this type could be very long.  I'd be hard pressed to feel I could prove that someone's emotions were telling them not to be socially connected and to stay inside -- what does that even mean?  Oh, truth be told, I write really boring notes.  In 20+ years no patient has ever asked to read their notes, and if they did, they'd find it a really boring read.

I'd love you're input, but comments are still off while the blog settles down. 


Sunday, July 06, 2014

Guest blogger Dr. Sana Johnson-Quijada on Freedom and Self Care

I met Dr. Sana Johnson-Quijada at the APA Annual Meeting this year in New York.   Sana has her own blog Friend to Yourself, and I invited her to do a guest blog on Shrink Rap.  In honor of Independence Day, she sent the following post. 

Self-Care is Freedom, is Democracy, is Because We Are Accountable

Self-Care Tip #159 – Be accountable for and to yourself.
It was about 100 degrees Fahrenheit, which in my part of the world is considered hot.  But in Washington D.C., I considered that temperature general anesthesia.  I was breathing it in and trying hard to remain alert.  Just when I thought I could hold out no longer, I saw him.  Big and expressive, the long form of Abraham Lincoln was there, surrounded by loud irreverent people.  My brother and I were wiping sweat out of our eyes trying to keep track of our kids.  We wanted to read the Gettysburg Address for our kids, and found ourselves screaming.  The kids could barely hear the words above the disinterested rabble around us.  Despite all this, I was choking; a weepy, sweaty, nearly anesthetized but free American.
Four score and seven years ago our fathers brought forth on this continent a new nation, conceived in liberty, and dedicated to the proposition that all men are created equal.
Now we are engaged in a great civil war, testing whether that nation, or any nation, so conceived and so dedicated, can long endure. We are met on a great battle-field of that war. We have come to dedicate a portion of that field, as a final resting place for those who here gave their lives that that nation might live. It is altogether fitting and proper that we should do this.
Just down the corner from Lincoln is a president’s list of sites to see, informers and reminders of who we are and where we came from.  However, none of them were “my Lincoln” experience.
But, in a larger sense, we can not dedicate, we can not consecrate, we can not hallow this ground. The brave men, living and dead, who struggled here, have consecrated it, far above our poor power to add or detract. The world will little note, nor long remember what we say here, but it can never forget what they did here. It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us—that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion…
A couple of days ago, writing the post about how stress intersects with medicine, I remembered “my Lincoln.”  It may seem like a stretch at first but take a minute.  Self-care is a way of saying, “I am free.”   In places where life is cheap, almost without value, self-care is not much of an option.  It is because of freedom that we can extricate the meddling fingers, the invasions, and be the keeper of our own private spaces however we choose to.  It is because of freedom that we can tell people that although my brain is ill and although I take medication, I am equal. Saying that is self-care.  Saying that is possible if we take that freedom to keep our own accountability for our own selves.  Accountability is not the same as blame.  Having accountability for our freedom is not the same as being at fault for what came before freedom, nor our current conditions.
—that we here highly resolve that these dead shall not have died in vain—that this nation, under God, shall have a new birth of freedom—and that government of the people, by the people, for the people, shall not perish from the earth.
If you’re not accountable to your inner self, if you’re only accountable to your actions, or you’re only accountable to what others determine and define about you, than you are not free.  You are blamed.
Accountability is such a tender privilege.  We might lose it if we forget who we are, where we came from and our rights to freedom.  Democracy is self-care.
Question:  How do you see the relationship between self-care and your freedoms? 
I practice psychiatry and parent, with my husband, our 3 small children.
Woven into this, writing and connection to community continues to bless me.  I am grateful.