Tuesday, December 29, 2015

Happy New Year: What are Your Hopes for Mental Health Policy in 2016?

Happy New Year!
So the end of the year has me reflecting on the things that have..well...annoyed me a bit this past year, and about the things I'd hope could be different.  It gave me a chance to take stock and come up with my wish list, which is up on our Clinical Psychiatry News website Here.
Do surf over and let me know what you think.
What did I miss?  What would you like to see change?

Monday, December 28, 2015

I Owe You What?

The question of agency in psychiatry is an interesting one.  To me, it's clear: I'm the agent of my patient, it's his best interest that I care about.  But the odd thing is that society periodically asks me to assess patients for their interests. 

 Is my patient able to serve on jury duty?  He tells me he's very anxious, in fact he's taking medications for anxiety, and he has some health issues, and everything about jury duty is hard here in the grand city of Baltimore.  There's a daily stipend; it doesn't cover the parking fee.  You have to negotiate downtown traffic, park in a garage, walk to the courthouse, and if you're put on a criminal trial, there is the fear (albeit the risk is perhaps quite small) that you or your family could be in danger if you vote to convict a gang member.  The seats in the waiting room are uncomfortable, the temperature is always wrong --either way too hot or way too cold. Serving doesn't mean you'll ever be called to a court room, I've spent 8 hours in a freezing waiting room to then be dismissed at the end of the day.  Okay, but here it's not the court asking, it's the patient asking -- but the point is that if I say someone can't serve, they get a free pass. 

What about driving? Periodically, someone gives me a form to fill out for DMV regarding their safety to drive because they carry a psychiatric diagnosis .  I'm not aware of any purely psychiatric diagnosis --with the exception of dementia --which leaves one unable to drive, and invariably the patients does wish to continue driving. Driving helps get to appointments and to obtain medications and food, among other things. Usually it's people with schizophrenia or bipolar disorder who show up with the forms.     I have never witnessed any of my patients drive; if I did, I still wouldn't know how to judge; driver safety assessment is not taught in medical school.  And many patients talk about having multiple accidents, unrelated to any diagnosis or substance issue (they're just lousy drivers) and they never show up with forms. 

A difficult one is the people who show up with forms for clearance  for a new job.  If they are bringing me a form, it means they've told the employer or the human resource folks that they have a diagnosis.  Often, it's my opinion that it would be in their best interest to at least try working --- work adds structure and meaning to a life, it often adds health insurance (a very good thing), and it adds money which allows for food, housing, medications, entertainment, and opportunities for fun, all of which improve mental health! 

 Sometimes, however, I'm not sure if my patient will be able to do the job --- like driving, I was not trained to assess the ability to work.  Sometimes I can see there might be problems -- the patient misses appointments because they get too depressed to get up, or they have executive functioning issues where they simply don't organize their lives well ("Oops, I forgot I scheduled 3 appointments at the same time!").  But still, if they want to work, and if they can, it would be in their best interest.  Now, obviously, there are some exceptions here where it's not in my patient's best interest to take a job -- for example if there's been a history of repeated suicide attempts or violent behaviors, then perhaps it doesn't make sense for me to clear a patient for a job if it requires that he carry a firearm.  But mostly, it's more benign stuff and I've seen people who can't get to an appointment reliably, but can manage a job -- either they prioritize getting to work, or they have jobs that value performance more than punctuality.  And many people negotiate successful work lives around substance abuse problems, especially if they can limit the substances to after-hours.   And there, too, there is a check on the system that doesn't fall on me; jobs where sobriety is crucial usually include drug screening.

So what's my obligation here?  The patient the wants the job.  No one's life will be in danger if she fails, though with some people, job failure can be a huge emotional setback.  The structure, purpose, and money will all be be good if the patient can manage to  work.  But there are these forms that I've been handed with a long check list of  questions regarding the ability to perform tasks where I have no idea, or I suspect that, based on history, the patient may not be able to do --like show up, attend to detail, demonstrate organized thinking-- but I could be wrong, because I have been before, and a work setting is different from a psychiatric office.  If I say I don't think the patient can perform, they don't get the job and they lose the chance to try. 

In my head, it's a dilemma.  There is no question that I am the agent of the patient and that I owe nothing to a patient's potential employer with whom I have no relationship just because they send a packet of papers.  I want what's best for my patient, but as human being, if I have reason to believe the patient can't perform a task and I say they can, then I'm basically lying.  None of it feels right.  

Psychiatrists (and perhaps doctors as a whole) have ended up in these strange places.  We often don't know if our patients can work, serve on a jury, drive, own a firearm safely, go to summer camp, or manage the stress of any given situation.  New settings can be stabilizing or destabilizing.  I'm not sure how we got to be the gatekeepers on such things.

Your thoughts?
So when I'm 

Monday, December 14, 2015

Film Preview: Touched With Fire

I went to a really fascinating event tonight: a screening for Paul Dalio's film Touched With Fire.  The film was named for Kay Redfield Jamison's book, and in fact, Dr. Jamison made an appearance in the film!  She's a woman of many talents, and now she can add movie star to the list!  After the film, which was introduced by Ray DePaulo, the Psychiatrist-in-Chief at Johns Hopkins Hospital, there were some comments and a Q & A session with both director Paul Dalio and psychologist/writer/researcher/film star Kay Jamison.  I mean really, the only thing missing from this memorable evening was wine & cheese and the opportunity for selfies.  

So first, let me give you the advertisement for the event, then I want to talk about the film.  Here's how it was sold:

Touched with Fire, Paul Dalio’s feature film debut starring Katie Holmes and Luke Kirby, revolves around two bipolar poets whose art is fueled by their emotional extremes. Katie Holmes stars as Carla, a talented writer who struggles with the disorder and its management. After a particularly intense manic episode, she ends up in a psychiatric hospital where she meets Marco (Luke Kirby), another talented writer who refuses to stay on his medication because it fuels his intense creativity.  When they meet, their romance brings out all the beauty as well as the darkness of their condition, and its impact on their lives, families, careers and future.

Drawing inspiration from his own life experience with bipolar disorder, Dalio wrote and directed the film which includes strong performances by Griffin Dunne, Christine Lahti and Bruce Altman. Kay Jamison, author of the book "Touched with Fire," the definitive work on creativity and madness, makes a cameo. It was produced by Jeremy Alter and Kristina Nikolova, who also served as the film’s co-cinematographer. Spike Lee, Dalio’s professor at NYU Film School, is executive producer. The film will be released theatrically in February 2016.
Touched with Fire takes the audience on an authentic journey through the highs and lows of bipolar disorder and how it impacts not only individuals but their friends, families and work life. It is an outstanding film that offers a holistic portrayal of mental health and provides audiences with an inside look into one of the nations’ most discussed and least understood mental health conditions.
Paul Dalio sees this film as a catalyst to change the way bipolar disorder is discussed and we are using this event as one of many ways to start changing conversations.
 Okay, so before I start talking about the film, I want to warn you: plot spoilers follow.  If that's a problem for you, stop reading now.  I do apologize, but their is no way I can talk about this incredible movie without discussing the plot.

Carla and Marco are two poets who meet in a psychiatric hospital.  Group therapy feels a bit like a college seminar with a little psychosis thrown in, and the facility looks more like a middle school. There is wonderful collection of books with painting by Van Gogh,  photos of brain scans, and astronomical maps. There are art supplies galore.  Carla and Marco are bright, attractive, creative people, and what a relief to have people with mental illness portrayed as normal looking people who don't have strange mannerisms or dress in plastic bags.  They aren't pushing grocery carts, but they aren't doing well, either. They are human and likable, and Marco in particular comes off as being educated, brilliant, and in possession of this wonderful passion for life -- if you can overlook his constant pain and alienation.

So both patients have insomnia, and every night at 3 AM they meet in the activity room.  Van Gogh's Starry Night is projected onto the wall, and they connect with an intimacy that is, well, the stuff that movie love is made of.  And besides that, they build a sculpture out of the plastic chairs by piling them up, putting Play Doh on them, and sticking forks in the Play Doh, and they talk about going away (metaphorically, that is), to another place or planet. If they get lost, meeting back in the pages of the Van Gogh book.  All goes well until the psychiatrist decides they should be sleeping, not connecting, and they drug the night aide with their sleeping pills to continue with their rendezvous.  Ah, that doesn't end well, and when the well-meaning doctor tries to separate them, Marco throws some books, pushes a chair, they cling to each other, only to be separated by guards -- they end up sedated and restrained in their separate seclusion rooms.  Really?  And now it looks like an old psychiatric hospital. This was the first point where I felt some angst for the characters.  It seems like there should have been some kinder, gentler way to deal with this.

After discharge, the couple find each other -- they meet up in front of the genuine Starry Starry Night -- and their romance begins.  Their parents don't approve: two bipolar patients have to be bad for each other.  Again, I had another Really? moment.  Okay, maybe it isn't meant to be: people often connect in the hospital and when they leave, the connection ceases to be, but is a preconceived stereotype that two people with bipolar disorder are bad for each other.  Honestly, I wanted the parents to rejoice in their relationship -- if it didn't work out, then so be it, relationships often don't.  

Marco really struggles.  The medicines make him numb and lifeless, he simply can't feel.  And his well-meaning doctor doesn't offer to work with him to find something better; instead he tells Marco that his moods have been extreme and unregulated for so long that he doesn't understand what 'normal' feels like -- a stance Marco rejects.  In a world presented as either/or, Marco chooses mania, and he and Carla both end up off their meds after ceremoniously dumping them into a park fountain.  When they drop off the radar for a bit ---enjoying nature, each other, and love propped up by mania -- Carla's mother cajole's her into a get together, under the guise that she will accept Marco.  But oops, all the parents show up with Marco's doctor and the men in the white coats.  My third moment of Really?  They weren't bothering anyone. 

So Marco and Carla run off and have these wonderful moments bathing in lakes and driving through gorgeous mountains.  It's all good until the police try to pull them over and Marco's answer is to drive into a river.  Back in the hospital, it's revealed to all that Carla is pregnant -- something the couple wanted.  They promise to stay on their medications, be responsible, and everyone prepares for the birth of this baby, whose job it will be to make them whole, and to be comfortable on this planet.  

Only Marco can't do it.  Carla arranges for Marco to meet Kay Jamison -- a writer he idolizes-- who assures him he can stay on medication and still feel passion and be creative.  Marco, however, doesn't buy it -- Jamison, he decides, is a fake.  She writes about great artists because she can't be one!  He stays off his medications and becomes exuberant, magical, and then insistent -- while painting Starry Night onto the baby's nursery wall, he loses it and pushes pregnant Carla to the ground.  

Carla reappears to a 'baby shower' Marco has thrown with their parents gathered around the crib -- there are balloons and champagne, and Marco presents Carla with a gift-- The Little Prince -- a book in which the prince comes from another planet.  He announces the unthinkable: Carla has had an abortion.  Untreated mental illness has driven this relationship has come to its inevitable end.  Ugh.  I wanted it to work.

Time passes, and in the closing moments of the film we get our "happy ending."  Carla and Marco come together for a book store reading of a book of poems they wrote together when they were pregnant and manic.  Marco is on his medication, and Carla is doing well ---her father is proud of her and she has a new boyfriend.

In the discussion after, we learn that filmmaker Paul Dalio struggled with much of what Marco struggled with: how to manage his bipolar disorder without crushing his creativity. Dalio, too, met with the real life Kay Jamison who served as an inspiration to him.  

Dalio and Jamison talked about bipolar disorder as a "gift," a subject that came up in the movie.  I wondered, is bipolar disorder the gift, or are these two tremendously talented people who happen to have bipolar disorder? They talked about all they could do after bipolar disorder that they couldn't before, and I wondered -- is it the illness, the experience of the illness, or do people just find more talents as they age and mature.  After all, bipolar disorder often strikes young and we all grow into ourselves, with or without an illness.

Finally, I want to reiterate that I really wanted this couple to work out.  I wanted them to continue to rejoice in their love, to manage their lives,  and to have their baby with the happily-ever-after coming before the last few minutes.

The movies was the absolute best ever film portrayal of bipolar disorder; the people were real and they were so much more than their illnesses as they moved through each stage -- manic, desperately depressed, suicidal, and finally, well.  

So I'm going to end with one final thought.  The film was presented as a realistic portrayal to destigmatize mental illness, and while everything about this film was rich on so many levels, I didn't think it destigmatized bipolar disorder. I didn't leave the theater thinking it would be fine if I or my children got this disorder. I didn't want my patients or their parents to see it if they were early on in the illness.  These characters were very sick; not everyone with bipolar disorder end up in and out of the hospital, not everyone destroys their careers, their love, and their unborn child.  I want my patients to feel more hopeful.   Kay Jamison and Paul Dalio are much more inspirational, hopeful examples of people living full and creative lives with bipolar disorder.  

If your goal is to understand bipolar disorder -- with all it's passion and pain-- then, hands down, this is the film to see. 

Thursday, December 10, 2015

Over-the-Counter Antidepressants?

Today's post is over on Clinical Psychiatry News, "Should SSRI's be Sold Over-the-Counter?"  
It's a question I'm asking just so people will flip the idea around in their heads a bit; it's not one I'm trying to sell.  

Please check it out Here, and do let me know your thoughts.

Thursday, November 26, 2015

Black Friday Shopping: Free Novels from Shrink Rap!

Happy Thanksgiving!

I realized that it's been a long time since I had a free promotion for my novels, and with Black Friday looming, I thought it would be nice to have Shrink Rap jump on the bandwagon with Black Friday shopping you can do from your living room, and with a great price, too: free novels.  The promotion goes for 4 days: Now through Monday 11/30/15.  If it goes well, I will set up another promotion for one day in December.

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 quick read with a little  psychiatry sprinkled in.
 The book was a page-turner because of elegant structure and pacing.  I really cared about the author’s take on things –because she is a psychiatrist? because I’ve followed  her blog for a while?– which meant that I was interested in the protagonist’s thoughts, feelings and actions.  At times I ached for the mess her life was in, at others I wanted to shake her into action, and then she’d find her backbone again, just in the nick.  

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.  
  I like to read all sorts of books, but books where there's something in it that reflects a part of me, a part of my life, a part of my experiences, are something I go out of my way to find. I have not found any fiction book that does nearly as much to show what psychotherapy is like.

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. You don't need to buy a Kindle to read on your computer, tablet, or smartphone.

There is is a single link to my Amazon page with all my books here.
The price for Double Billing, Home Inspection, and a children's novel: Mitch and Wendy, are all $0 and can be downloaded instantly.

 Both are also available as as paperbacks from Amazon, but not for free.

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.   


The promotion starts Friday, so it's off to turkey and family for today.  Wishing you all a gentle holiday.

Monday, November 16, 2015

Do You Need a Psychiatrist? In Maryland? Now?

Have you tried to find a psychiatrist lately?  It can be hard.  Of course, there are your insurance panels, if the docs listed aren't dead or listed in error and are taking patients.  And sometimes, people just get lucky and make a call to happen upon a psychiatrist they like a lot.  
It can also be a hassle, and to someone who contacted me recently, "If I didn't have an anxiety disorder when I started looking for a psychiatrists, I'd have one now!"

I can push an icon on my phone (Open Table) and find out in a matter of minutes exactly which restaurants in Baltimore can take a party of 6 at 7:45 tonight, or another icon (Uber) to get a driver to take me to that dinner me in minutes, but there's not an easy way to figure out who can see a patient quickly -- it's hit or miss and often a matter of luck or who you know, even when there may be doctors with time, or perhaps someone who had a bunch of unexpected cancellations one day.

I thought I would try to rectify this situation in Maryland and in less than an hour (~I've had a little practice with these website things), I was able to set up an Access to Care website in Maryland, located at MarylandPsychiatrists.net.  Do check it out, and each week, more and more psychiatrists have registered with openings.  I'm trying to get the word out that the website exists, so if you're a doctor in Maryland, do let folks know.

Friday, November 13, 2015

If You Don't Get Better, We Can Always Kill You

My co-blogger, ClinkShrink, has very strong opinions on Physician Assisted Suicide.  My personal opinions are less strong, though with 40,000 suicides in the US every year, I'm not sure why it's necessary to involve physicians as the agents of death; we went into this field to help people, not to kill them.  But I don't believe that every suicide is necessarily either the result of mental illness or a tragedy.  We all die, and for myself, if all that remains of my life is suffering, I'd like to go quickly.  Clink and I say that she's worried they'll knock her off too soon and I'm worried they'll keep me around too long. 

But what about psychic suffering, which by anyone's measure, is just as bad, if not worse than physical pain.  I've had a patient tell me that his cancer treatments with all their complications, didn't compare to the pain of his depression.  And certainly, many people do decide that their psychic pain is unbearable, or believe they've become a burden to others, and so end their own lives.  But should doctors have a role in this?  Should we kill people because they have treatment-refractory depression?  I'm thinking that's not a good idea and please don't show up at my office looking for your lethal prescription.

In Belgium, psychic torment is an acceptable reason for euthanasia. And they even have a menu: you can drink a potion, or a doctor will administer a lethal injection.  That's right, in the land of beer and chocolate, the doctor will actually murder you in the name of medicine. 

 The YouTube above is haunting.   Emily has struggled with depression for a dozen years, and she's been approved for euthanasia.  I'm going to tell you that Emily changes her mind at the end because if you don't know that this lovely 24 year old young woman lives, it's unbearable to watch. I find it hard to imagine that there is ever nothing that can be done to alleviate at least some of the pain ...even if it's ECT or ketamine, or TMS, or a few cocktails to temporarily numb the pain (~if you try that one, please don't drive afterwards) and no hope of a new treatment that might make it better.  In this case, the events of the two weeks prior to her death date -- time spent meeting with friends to connect and say goodbye, getting ready -- were a period where the pain eased up.  Emily felt better knowing there was a way out, she found hope in the prospect of death.   

Tuesday, November 10, 2015

Who oversees medication pre-authorization?

Have you ever tried to get a medication preauthorized for your patient, only to be told "no" the insurance company won't pay for your patient to have the medication you say they need?  I've been trying to get a medication authorized, and I decided to see this through.  In some cases it seems there is no end to the hoops the insurance company can set, and no time frame for when they must answer.  Read my account here on the Clinical Psychiatry News website. 

Sunday, November 08, 2015

10 Steps to Change the Stigma of Psychiatric Disorders for Better or for Worse with some Surprises

It's someone's mantra: the number one barrier to getting mental health treatment is stigma.  Maybe it's true and I'm not looking at the research, I'm writing from my own impressions (It's my blog...)

I'm going to suggest that the barriers to getting mental health treatment are
~1) Access.  Half of all counties in the US don't have a mental health professional (I saw that on Twitter, so it must be.)  That's any mental health professional, not just psychiatrists.
~2) Access.  If there's somewhere to go there may be many weeks to wait.  People don't like to wait and some of those people just won't make appointments far off; some will feel better before they actually get in and won't show up.
~3) Cost.  Over half of psychiatrists don't participate with insurance, the upfront cost of care is very expensive, and insurance companies vary in how well they reimburse out-of-network care and won't tell you what they reimburse before you file the claim which they may or may not lose or reject.
~4) Shame or embarrassment,  so stigma.
~5) The urgings of others who disapprove of the use of medications, don't believe in psychiatrists, don't want to foot the bill for relatives, don't want to take off work to drive a relative to appointments.
~6) Distrust of psychiatrists and the pharmaceutical industry

Somehow, we've become a culture that believes that if you say "End Stigma" you're doing something to end stigma.  Or that if you come out and announced all the awful things your mental illness has led you to do, that this ends stigma.  Bill boards are big.  Or that if you're a politician who says "We need to end stigma" while passing stigmatizing laws, that you're ending stigma.

So what decreases stigma.
1) When successful celebrities announce that they've struggled with mental illness, particularly if they have not made a spectacle of themselves and if they haven't led chaotic lives.  When Andrew Solomon talks about his struggles with depression, as he rakes in his many writing awards and gives his incredible TED talks, that's destigmatizing.  Brittany Spears -- not so much.

2) When regular people talk about their struggles with mental illness: especially if they are employed, married, and living productive lives.

3) This won't be popular but: Television commercials for pharmaceutical agents and direct-to-consumer advertising.  It's everywhere -- someone must be taking those medications and the ads normalize it.  It may be bad for all sorts of other reasons, but in terms of decreasing stigma, they help.

4) Parity for insurance so that mental health treatments aren't different/less than 'real' medical conditions.

What Increases stigma:
1) Anything that alters civil rights based upon the existence of a mental health diagnosis in the absence of a troublesome behavior.  So laws that restrict the purchase of guns by people with a mental health diagnosis, even if they've never done anything dangerous or threatening.  Or proposed laws that want to say that people with a diagnosis of a psychiatric disorder should be the only people who can't forbid their treatment team from releasing their diagnostic and treatment information to their family/caretaker.

2) Comments about keeping guns out of the hands of crazies.  ('nuff said).

3) Linking mental illness with mass murder.  I think.  I actually have never had a patient who has expressed any sense that being in psychiatric treatment in any way associates them with someone who does heinous things.  But it can't be a good association.

4) Fears of being made/coerced into to take medications when you don't want to take them and the concern that one's autonomy and individual decisions won't be respected.  Who wants to sign on for that?

5) The side effects of our medicines.  There's nothing desirable about being overweight, having metabolic syndrome, being sedated, having a tremor, or having other movement disorders.  

6) The devastation associated with untreated mental illness -- unmet potential, sometimes unemployability, homelessness (or being stuck in a parent's basement), incarceration, poor hygiene, odd behaviors.

So what did I miss?  I'm skeptical about the idea that Modern Family's Halloween episode with scary 'mental patients.' actually increases stigma -- it's a historical stereotype and it's too outrageous to feel like anything accurate -- but I certainly do understand that this is very offensive (I'm just not sure that all that is offensive is  stigmatizing).  By all means, feel free to correct me here.  And feel free to add to the list.

Tuesday, November 03, 2015

More Psychopharm...

I know, I know, the conference was over more than a week ago.  I'm writing these posts more for myself, as a way to review what I learned and stabilize it in my head. Thanks for bearing with me. 

Dr. Alpert on Drug Interactions:

There are online drug interaction checkers.  
~Prozac interacts with Coumadin. 
~ Geodon needs to be taken with meals or it doesn't get absorbed.  ~Some medications decrease the efficacy of oral contraceptives including carbamazepine (Tegretol), Provigil, St John's Wort).  
~Oral contraceptives can also increase the levels of valproate and lamotrigine.
~Some SSRI's decrease the efficacy of Tamoxifen.  

Dr. Henderson on Managing Side Effects of Antipsychotic Agents
~Interventions for weight gain: Switch agents
~ add: sibutramine, orlistat, topirimate, buproprion, metformin
~worry about prolactin levels and tardive dyskinesia.
~Omega 3 Fatty acids (1-2 grams of EPA =DHA) may reduce cardiac risk

Dr. Perlis on Emerging Treatments in Bipolar Disorder
What we know: Not very much
~Brexpiprazole (Rexulti) is similar to Abilify.  There is no data for its use in bipolar disorder.
~New for bipolar depression: Lurasidone (Latuda); Armodafinil (Nuvigil)-- not FDA approved.  rTMS.  Ketamine--effects fade in days.  
~?Low frequency magnetic stimulation, after an MRI tech noted that people got happy during their MRIs.
~Pregnenolone (a steroid hormone precursor)
~Pioglitazone (Actos) as a lithium add-on

Dr. Papakostas on New Treatments for Major Depression
~Vortioxetine (Brintillix).  Start at 10mg, back down to 5mg if side effects (nausea is common, also sleep disturbance), can go to 20mg.
~Executive dysfunction is often seen in mood disorders.  
~Both duloxitine andvortioxetine improved memory
~Geodon for augmentation (ziprasidone, better than placebo)


Tuesday, October 27, 2015

More of What I learned at the MGH Psychopharm Course

 I'm back in Maryland, but I am still thinking about all that I learned at the MGH course.  Let me see what else I can add of interest.  Let me put in a plug for the course: It was an excellent catch-up class on practical aspects of psychopharm.  Highly recommended, and I'll go again in a couple of years.

Dr. Bianchi on sleep disorders, mainly insomnia
~Medicines of all types change sleep architecture and reduce REM sleep. There's no evidence that these changes have meaningful clinical correlates.
~Melatonin -- start at 0.5mg and go up, take 3 hours before sleep, and it's contraindicated for patients on coumadin.
~People's perceptions of their sleep is not accurate.  Ambien increases total sleep time by 40 minutes; people estimate they've slept two hours longer.
~Trazodone doesn't work. (I'm just the messenger here)
~Suvorexant (Belsomra) -- the first orexin antagonist.  There were safety concerns at the higher dose and efficacy concerns at the lower dose which was FDA approved.
~You can try herbals and lavendar drops on your pillowcase
~20-50% of insomniacs have sleep apnea. Even if they are skinny and don't snore.  Who knew?
~CBT! Try an online course, but if you need to know, there are 8 clinics in Boston that offer CBT specifically for insomnia.

Dr. Freudenreich on First-Episode Psychosis 
~The average time from onset of psychotic symptoms to starting treatment is 74 weeks
~In one study, giving patients with a psychotic prodrome 12 weeks of fish oil dramatically decreased the number who went on to be diagnosed with schizophrenia.  
~Adding metformin to the regimen may improve metabolic parameters
~New stuff: Brexipiparzole (Rexulti) and Invega Trinza (a long acting injectible that can be given once every 3 months).
~Best antipsychotic is still Clozapine.

~While medications prevent relapse of psychotic symptoms, they are not comprehensive treatment for schizophrenia.

More later.


Monday, October 26, 2015

I'm sorry, now which box did you want me to write my NPI number in?

I'm soliciting wisdom from our readers on how to fill out a HCFA claim form.  I'll start by telling you that my NPI number on the submitted form was in block 33A.  My legacy number was not on the form.  This is the third such notice I've gotten, and clearly, I'm doing something wrong.  Perhaps you can help?

Saturday, October 24, 2015

What I'm Learning at the MGH Psychopharm Conference, Continued

Moving right alone here, but I'm now many lectures behind.  I'll do my best:

Dr. Jenike on Obsessive Compulsive Disorder
"It's almost unheard of to have a patient get all better."
~SSRI's are the usual medication, often at higher doses than used to treat depression.
~Cognitive Behavioral therapy is the best augmenter.
~MAOIs may help with OCD with panic attacks.
~Lots of other stuff has been tried including Dilantin, Neurontin, morphine, Zofran, pindolol, tramadol St. John's Wort, inositol.
~Glutamate may be involved in OCD and medications that effect glutamate have shown some promise, Including Namenda (memantine), riluzole (a medicine used to treat ALS), and N-Acetylcysteine
~In sudden onset of OCD, consider infectious etiologies, including PANDAS (Google it)

Dr. Simon on PTSD
~propranolol doesn't seem to prevent PTSD (sorry, Roy)
~People who get opiates may be less traumatized -- better pain control likely
~steroids may have some some role in preventing PTSD if administered soon after a trauma
~Don't use benzos for PTSD, they interfere with extinction learning and ultimately make PTSD worse.
~Don't use benzos for PTSD.
~Prazosin helps with nightmares. Lunesta may help with insomnia
~SSRIs help, but not a lot.  Risperidone and quietiapine may be helpful, there is not enough data to say much about other antipsychotics.
~There's not enough data to support that smoking marijuana is helpful.
~We need more research.

Dr. Zakhary on OCD-related disorders: Body dysmorphic disorder, trichotillomania (hair pulling), skin picking and hoarding
~There are no FDA approved medications to treat these disorders.  Check out http://Trich.org
~People with body dysmorphic disorder can spend up to 8 hours/day looking in the mirror.
~SSRIs may help.  There is no indication for using an antipsychotic even if the patient is delusional.
~Tricotillophagia is the name for eating the hair after it's been pulled out.  You learn something new every day.
~N-acetylcysteine may be helpful (NAC), dose of 1200mg -2400mg/day.  Brand names Jarrow or Swanson, and you can get it from Amazon.  Swanson is cheaper.
~Also Naltrexone at 50-100mg, or Olanzapine, 10mg/d
~For skin picking: SSRIs may help.  Olanzapine 5mg/d, Abilify 5-10mg/d, Lithium, or Milk Thistle. It's all case reports.
~An itch workup should be done.
~Hoarding: medications studies are inconsistent and very limited.  CBT!

So, I've gotten you to 5:15 yesterday.  I went to sessions on Sleep Disorders (avoid meds, refer for >CBT!, and apparently trazadone doesn't work) and Natural medications for psychiatric disorders at night, and then dinner at a wonderful French restaurant on Newbury Street with a friend.  It made for a late night, and it all started over this morning with more to come tonight, and all day tomorrow.

Thanks for listening.

Friday, October 23, 2015

What I'm Learning at the MGH Pscyhopharm Conference (Part 0.5)

Greetings from Boston!

I am here, with 750 or so psychiatrists, at the Massachusetts General Hospital's 39th annual psychopharmacology conference.   I wanted to update my medication knowledge, and the meeting runs through the weekend.  The day has been stuffed with useful information, and really good lectures -- much too much to blog about and there are still 2 hours left tonight.  Let me just give you a sample from each lecture:

Dr. Nierenberg on Bipolar Depression:
He suggested checking out MoodNetwork.org
"Bipolar depression is really hard to treat; so many people don't get all the way better."
~People can be depressed, manic, anxious and irritable all at the same time.
~Antipsychotics and a  mood stabilizer aren't much better than antipsychotics alone.
~There are 4 FDA approved treatments for bipolar depression: olanzapine/fluoxetine combo, quietipine (Seroquel), Lurasidone (Latuda), and Lamotrigine (Lamictal)
~Seroquel's response rate is the same for 300mg as for 600mg
~Latuda's response rate is the same for 20-60mg as for 80-120mg
~Lamotrigine is not approved for the acute treatment of bipolar depression, but for prevention.  It is well tolerated.
~Lithium + Lamictal are more effective to prevent depression than mania.
~Some people use antidepressants alway, some never : the experts can't agree.
~Low dose Abilify has been disappointing in bipolar depression.
~Single dosing at night may prevent renal complications.

Dr. Perlis on Long-term management of Bipolar Disorder
You only know if someone has bipolar depression after they've had an episode of mania; family history or early age of onset don't make the diagnosis if the patient is depressed.
~Effective antimanic agents: lithium, valproate, carbamazepine, any antipsychotic.
~Lamictal, gabapentin, and toprimate have not been shown to be effective for mania
~Lithium decreases the risk of suicide.
~Aim for a level of at least 0.6, but risk of renal damage increases with time (decades) and levels (>0.8)
~Lithium and valproate are better than valproate alone
~This guy likes lithium.

Dr. Fava on Treatment-resistant depression
Strategies: increase dose, change medications, augment, combine.
~Buspirone is a safe agent to use for augmentation
~Mirapex (pramippexole) --can go gradually up to 1.5mg bid
~There is some way to get a compounding pharmacy to make intranasal ketamine, but this needs to be monitored.
~Lots of stuff has been tried.

More later --  

Wednesday, October 21, 2015

News Flash: Psychotherapy is Helpful in Schizophrenia

In yesterday's New York Times, there was an article by Benedict Carey titled New Approach Advised to Treat Schizophrenia.  Carey writes:
Now, results of a landmark government-funded study call that approach into question. The findings, from by far the most rigorous trial to date conducted in the United States, concluded that schizophrenia patients who received smaller doses of antipsychotic medication and a bigger emphasis on one-on-one talk therapy and family support made greater strides in recovery over the first two years of treatment than patients who got the usual drug-focused care.
And I thought: This is news?  Obviously, anti-psychotics have side effects, adverse effects and risks, so using using the lowest effective dose is good.  If it takes a high dose of medication to quickly control an acute episode, it's often possible to back down on the dose after the condition has been stabilized.  Talk therapy is often helpful, and of course family support makes all the difference in the world to anyone with a chronic illness or disability.

I was relieved to see that Peter Kramer's tweet:

Oct 20
Psychotherapy helps in schizophrenia = what psychiatrists in my cohort have always believed, as a guide for practice
So I wasn't imagining that this "news" was obvious.  

Later, Dr. Mark Komrad wrote in to our psychiatric society listserv:

"Everyone is talking about this big finding reported in today's NYTs. I'm not sure what's new here. Isn't this how we have been treating schizophrenia all along?  At least everyone I know who treats schizophrenia uses all of these techniques--both in private offices and clinics. What am I missing?  Maybe the lower doses of meds--but don't we all try to use the lowest doses possible?"  

If you'd like to look at the original article, the link is Here
The study by Kane, et.al is notable for the following:
There were 404 individuals enrolled in 34 community mental health centers in 21 states.

"The experimental treatment, NAVIGATE (19), includes four core interventions: personalized medication management (assisted by COMPASS, a secure, web-based decision support system developed for RAISE-ETP); family psychoeducation; resilience-focused individual therapy; and supported employment and education (SEE)."

In case you're interested, in Maryland, the wait-time to get into the agency that does supported employment is 16 months and there are currently 2,586 people on the wait list.  That's not related to the study, but I just thought you might like to know.   Getting back to the study now:

"The control condition, “community care,” is psychosis treatment determined by clinician choice and service availability."

Assessment of the outcomes was made in the following way: "Trained interviewers using live, two-way video conferencing performed diagnostic interviews and assessments of symptoms and quality of life."

Select Results -- I've copied and pasted them, picked out only the ones I thought might be relevant to our readers, and taken out some of the statistics: 

  • Participants assigned to NAVIGATE remained in treatment longer than community care patients (a median of 23 months compared with a median of 17 months, and were more likely to have received mental health outpatient services each month than community care subjects (a mean of 4.53 services, compared with a mean of 3.67 services);
  • NAVIGATE participants experienced significantly greater improvement during the 2-year assessment period than those in community care ; . 
  • More improvement was also found on the subscales “interpersonal relations,” “intrapsychic foundations” (i.e., sense of purpose, motivation, curiosity, and emotional engagement), and engagement with “common objects and activities.” Service Use and Resource Form data showed significantly greater gains for NAVIGATE regarding the proportion of participants who were either working or going to school at any time during each month. 
  • The average rate of hospitalization was 3.2% per month for NAVIGATE participants and 3.7% per month for community care participants. Over the 2 years, 34% of the NAVIGATE group and 37% of the community care group (adjusted for length of exposure) had been hospitalized for psychiatric indications (n.s.). 
  • Finally: Median duration of untreated psychosis was a significant moderator of the treatment effect on total Quality of Life Scale and PANSS scores over time . There was a substantial difference in effect sizes comparing the change between treatments for participants with a duration of untreated psychosis of ≤74 weeks and those with a duration of untreated psychosis of >74 weeks.

No where in the article does it say how medication doses differed in the two groups.  And while the NYTimes piece has been interpreted to say that psychotherapy is helpful in schizophrenia, the study adds a number of different interventions, a specific type of one-on-one psychotherapy being only one. Perhaps the bigger issue  rests with this statement in the researchers' conclusions, that long periods of untreated psychosis are hare more difficult to treat.
The observation that patients with shorter duration of untreated psychosis derived substantially more benefit from NAVIGATE is important. Prolonged duration of untreated psychosis is an issue of national importance; reducing duration of untreated psychosis from current level of greater than 1 year to the recommended standard of  less than 3 months should be a major focus of applied research efforts.

In sum: Patients with schizophrenia do better if they get comprehensive services, and they do better if they are treated early in the course of their illness.  And now we officially know what we all knew.

Saturday, October 17, 2015

Box 21

  I received an email from the APA the other day noting the following:

APA learned today that Medicare providers who file 1500 Health Insurance Claim Forms are having a large number of their claims returned due to a change in the reporting requirements that went into effect on October 1, 2015.

Medicare contractors are returning claims for correction or resubmission to mental health professionals who fail to indicate in line item 21 of the 1500 claim form whether ICD-9 or ICD-10 codes are used.
For services that were provided prior to October 1, 2015, ICD-9 codes should be used even if the claim is filed after that date; for services on or after October 1, 2015, ICD-10 codes should be used. ICD-9 codes are indicated by using a 9 in item #21; ICD-10 codes are noted with a 0.
Really?  The codes look totally different, Medicare can't figure out if the codes are DSM-IV-TR codes or ICD-10 codes?  Especially since it might be safe to assume that codes filed after October 1st are ICD-1O codes if they look like ICD-10 codes?  I generate the forms with a computer program, and I went to add the "0" to the template so it would automatically populate every form, but the program doesn't even have a box 21.  
As you may know, from the roughly 26 Medicare posts I've written,  I often feel jerked around by Medicare. In the past couple of weeks I got a form back saying that it was being rejected because I had my name,address, and NPI number in both box 32 and 33.  It does ask for it twice and I've supplied it this way for years.  I took it out of some of the forms, but not everyone's. Then I got a form back because my address was not in box 32 (I guess they couldn't get the information from box 33, millimeters away).  I added my address to box 32 and resubmitted the form.  I then got the same form rejected because my NPI number wasn't in box 32, but the first rejection said nothing about my NPI number missing.  (Again, it's in box 33 anyway).  

So, I'm waiting for all my October claims to bounce back, which seems like a tremendous amount of needless work for Medicare and a mild headache for me, and an unfortunate delay for my patients who count on timely reimbursement from Medicare.  Yes, yes, I know, this is why you've opted out.  I just can't get there without feeling guilty.

Wednesday, October 14, 2015

Preauthorization Frustration

In a note sent to my congressional senator:

I am a psychiatrist in Maryland  and I have become interested in the issue of the hoops that insurers require physicians to jump through to get preauthorization for medications.  Given that medicine, and psychiatry in particular, is a shortage field, it seems criminal that insurers can require physicians to spend hours requesting preauthorization for medications.  If the process were simple, this would not be so bad, and certainly some medications are quite expensive with cheaper available alternatives, but the process can go for weeks, during which time a patient can't get medications.
There are also many times when physicians are required to make these calls -- often taking 20-30 minutes-- for medications that cost only a few dollars a month -- the obstacles are mindless and they are hurting the delivery of medical care.  
Each state regulates this, but the issue often crosses state lines.  I have been trying to get a medication approved for a patient for weeks now -- I practice in Maryland, the patient lives in an adjacent state, her insurer  is in Iowa, and the pharmacy oversight agency is in Nevada.  I've been required to make multiple calls, all with hold times, where I am asked the same questions and told that the patient does not have medical necessity for the medication.  They ask the same questions at each step and tell me that while the case for the medication is good, they have no leeway to authorize it.  I have communicated with the CMO of the insurance agency who simply confirms that this is the process.

The process is well-illustrated by Danielle Ofri in a New York Times article last year:Adventures in Prior Authorization.  What she doesn't say is that there are no limits or regulation on how long an insurance company can delay or how many hoops can be set up.

I know Senator Cardin is sensitive to mental health issues.  Rep Murphy of PA has a bill in congress -- the Helping Families in Mental Health Crisis Act -- where he discusses the shortage of psychiatrists, but I don't believe it addresses this issue.


And in one of several emails to the health insurer's chief medical officer:

Yes it would be good if this process could be expedited.  I have been trying for weeks to get this medication for this patient.  I spoken to several people at both Catamaran (the pharmacy benefit agency) and Wellmark.  None would give their full names, and none had the authority to approve the medication if certain questions were not answered 'yes' and there was no room for individual consideration.  Yesterday, I saw the patient to get the release sign, and I noticed that the appeal and release are to be mailed (postal mailed that is) to different addresses, and only the release can be faxed.  I am going to assume that there might be some difficulty in getting these to the same place in a timely manner for review, and during this time the patient continues to suffer.  There seems to be no mechanism for electronic submission.  This process has taken now hours of my time, and it has been weeks.  I am going to attach the appeal letter in the hopes that perhaps as medical director you can get it to the correct place.  I will also mail it, and fax the release.  
Apparently I'm not the only frustrated psychiatrist, Dr. George Dawson at Real Psychiatry has plenty to say on the topic here:

Sunday, October 11, 2015

Forensic Psychiatry Steps into the Social Media Age

Regular followers of this blog know that every year about this time I put up a series of posts entitled "What I Learned." The purpose of the posts is to give people a peek inside the annual conference of the American Academy of Psychiatry and the Law as well as some exposure to the kind of topics forensic psychiatrists are interested in. General psychiatry residents may find it helpful, particularly if they are considering a career in forensic psychiatry and if they can't afford to travel to the conference. Our organization, AAPL, is an international group with members from Canada, the UK, Australia, and South America. Our international members deserve to see what's going on, as well.

This year, we will boost our international presence by livestreaming a select number of presentations through the Meerkat mobile app. Here is a schedule of the presentations we will stream. Directions on how to use Meerkat are below. In addition, select AAPL members have volunteered to moderate questions on each presention through Twitter. Hashtags will be announced through Meerkat, Twitter, and slides at the actual presentation. We've never tried this before, and we are all volunteers rather than professional videographers, so there may be a few snags or hitches but overall we're hopeful people will find it educational and fun. The conference begins on Thursday, Oct 22nd and continues through Sunday.

Here's the schedule:

Graham Glancy 
Witness Protection Program: A Matter of Training
Ken Appelbaum
The New APA Guidelines on Correctional Psychiatry
Ryan Wagoner
The Psychiatrist in Peril: Current Topics in Malpractice
Tobias Wasser 
Novel Approach to Teaching Residents About Violence & Safety
Drew Kingston PhD 
The Relationship Between Mental Illness and Violence
Caitlin Costello 
Adolescents and Social Medica: Privacy, Brain Development and Law
Robert Forrest 
Treatment of Transgender Inmates
Rosa Negron Munoz 
Educational Factors Contributing to Juvenile Delinquency
Madelon Baranoski 
Role of Forensic Psychiatry in Veteran Evaluations
Anna Glezer 
Myths and Realities of Women in Prison
Jennifer Piel 
What Gets Judges in Trouble?
Keith Stowell 
Forensic Issues in Emergency Psychiatry
Hal Wortzel 
TBI Update: International Collaboration on mTBI and DSM-5
Stephen Simring 
Forensic Psychiatry and the Death Penalty
Lynn Maskel 
Rock and a Hard Place: Debating Sexual Sadism Diagnosis

Here’s how you use Meerkat:
  1. First, go to the app store, search for “Meerkat app,” and download it.
  2. Meerkat will ask you to type in your phone number for verification. Then, they’ll send you a four-digit confirmation code.
  3. Next, connect the app with your Twitter account. (If you prefer, you can skip this step and check the app out in stealth mode.)
  4. If you don’t want to add friends, don’t connect your accounts. Simply scroll down and you’ll see anyone who’s live streaming right away. Keep scrolling for more.
  5. Search for and follow @AAPL2015. We will have a schedule of streams posted each day. For simultaneous sessions, AAPL members may use their own Twitter accounts which we will announce. You can search for them on Meerkat as well.

This is all a tremendous experiment so I want to thank my colleagues, AAPL, and our viewers in advance for participating. I'm looking forward to your questions, comments, and discussion.

--ClinkShrink AKA @ClinkShrink AKA Annette Hanson, MD Program Co-Chair

Thursday, October 08, 2015

Does psychiatric treatment prevent suicide?

For today's Shrink Rap post, please surf over to Shrink Rap News at http://bit.ly/1VHS6W7

I ask whether psychiatric treatment prevents suicide and interview VA epidemiologist and suicide guru Dr. Robert Bossarte.
Do check it out Here.

Monday, October 05, 2015

Did you take your pill today?

Proteus Digital Health has a device that allows people to track their medication injection.  A sand-grain sized ingestible tracker is built into the pill and the patient wears a sensor patch that monitors ingestion and the physiologic response (heart rate change, etc).  With the patient's permission, the information is communicated to his physician.  The technology has been around for a few years, and the fact is that half of patients take their medications wrong.

So what is new is that Proteus is applying for FDA approval to use their sensor with Abilify, an psychiatric medication. In a news release:

“Today, patients suffering from severe mental illnesses struggle with adhering to or communicating with their healthcare teams about their medication regimen, which can greatly impact outcomes and disease progression,” said William H. Carson, M.D., president and CEO of Otsuka Pharmaceutical Development & Commercialization, Inc. “We believe this new Digital Medicine could revolutionize the way adherence is measured and fulfill a serious unmet medical need in this population. We look forward to continuing working with the FDA throughout the NDA review.”

So what do you think?  Do you want to know if your patient is taking every dose of medication?  Do patients want their docs to follow them this closely?  I'd ask if we're worried about privacy issues, but is there really any medical privacy left to worry about?  Why psychotropic medications?  Shouldn't we be just as concerned with whether patients are taking their medications for diabetes or congestive heart failure?  Or perhaps we could track people who take antibiotics for Lyme disease and see if those who follow the antibiotic regimen exactly have a better outcome than those who don't.   

Some people like technology.  Roy would probably stick those little sensor things in his Flintstone vitamins, if he could.  ClinkShrink would monitor her ice cream consumption with it's physiologic responses (~her pupils get much bigger when she eats chocolate ice cream).  But don't we think that this has the potential --for better or for worse-- to be 'required' of patients to prove they've been compliant with court-ordered treatment.  For some, it might be a good thing.  If you're in treatment as part of a diversionary program with a Mental Health Court, you might want to be able to prove to the judge that you're taking your medications and you got sick anyway -- it wasn't your fault.  But I do think this technology, if approved, may well end up having a role in outpatient civil commitment to require patients to take their medications.

Schizophrenia expert William Carpenter, MD was interviewed for Psych News and he mentioned several concerns:
“The technology can provide important advances in addressing highly prevalent problems in patients adhering to medications,” Kane told Psychiatric News. However, Kane pointed out, major concerns regarding the use of this technology are likely to arise, such as how the information obtained by the device will be protected.

William Carpenter, M.D., a professor of psychiatry and pharmacology at the University of Maryland School of Medicine, agreed.

In addition to issues of privacy, Carpenter told Psychiatric News that convincing people who are already vulnerable to paranoia to take a medication that may be viewed as highly intrusive as well as the potential high cost of the medicine could present additional challenges.

Carpenter described several other questions about the therapy, including how best to determine candidates for the ingestible-sensor medications. Additionally, he said psychiatrists may need to consider questions such as, “Is this an acceptable privacy compromise in an involuntary commitment?” or “Will the device lead to fewer in-person visits with clinicians and reduce the chances for integrative treatment and early detection of relapse?”

Carpenter concluded, “Some [psychiatrists] will be ready for this innovative approach of treating mental illness, and if this device is successful—with little compromise to the patient—the field will embrace it.”
 At this point, it's just too much Big Brother for me.

Thursday, October 01, 2015

Renews your faith in our American medical system

My thanks to Dr. Laurie Cohen for posting multiple pages of bird-related codes on her facebook page.  And yes, Jesse, I'm trying to find codes for chinchilla-inflicted injuries.

Wednesday, September 30, 2015

Welcome to ICD-10

Today is October 1, 2015, and the day set for the long-awaited change in the system used to code medical and surgical diagnoses.  Say good-bye to the 17,000 ways that the International Classification of Diseases 9 let you be sick or injured, and now we have 70,000 new ways for all those events.

In psychiatry, it shouldn't be too bad, and I'm planning to spend my day in the office updating my computer.  The psychiatry blogger PsychPractice was kind enough to make a cross-over chart, and I'm hoping that will be helpful.  If it might be helpful to you, here is the link:


For others, it may not be such an easy day.  If you're having angioplasty today, yesterday your doctor had a choice of one code.  Today, she has 845 options, so do be patient with her, it's a big menu to choose from.  

There were jokes on Twitter about codes that would differentiate between being bitten by a duck in a thong or being bitten by a duck while wearing a thong.  Here at Shrink Rap, where the duck has been our long-time mascot, we don't think that's at all funny.

If you'd like a sample of some of the new codes, however, there is something for everyone.

For the creative types:
Y93.D1 Activity, knitting and crocheting

For the more active souls:

V91.07XA Burn due to water-skis on fire, initial encounter

 For those who can be a bit klutzy:

T71.231D Asphyxiation due to being trapped in a discarded refrigerator, accidental.  I couldn't find the code if someone was trapped in a refrigerator that hadn't been discarded.

And for those who are just really unlucky:

V9542XA Spacecraft crash injuring occupant – 

The codes can be very specific:

S30.867A Insect bite (nonvenomous) of anus, initial encounter

And we don't want ClinkShrink to feel left out, so there is

Y92.146 Swimming pool of prison as the place of injury

(And I imagine ClinkShrink will certainly be spending her day checking on the safety features of all those swimming pools in the correctional system here in Maryland)

Finally, there really are duck-related injury codes and they are kind enough to differentiate whether the patient is struck by a duck W6162XA or bitten by a duck W6161XA.  I suggest that you not do anything to provoke the duck.