Tuesday, June 30, 2015

Your Kidneys or Your Sanity: Two Bad Options

There's a article in the New York Times by Jaime Lowe titled, "I don't believe in God, but I believe in Lithium."  I had no idea the two were mutually exclusive or even had anything to do with one another!  The title aside, I liked the article. 

Lowe describes devastating bouts of psychotic mania, and how lithium enables her to lead a functional and productive life, with mental illness held at bay.  Until her renal function starts to tank. 

Lowe writes:
I wanted a calmer life. So for the next 13 years, I took my three pink capsules and all was well. I wrote a book, I learned how to cook in an Italian-restaurant kitchen, I had a few relationships that lasted longer than a month, I wrote, I boxed, I traveled, I painted, I took my pills. I was fine.

Then, last fall, I saw my primary physician — and he sent me to the nearest emergency room. He was alarmed at my combination of high creatinine levels, damaged kidneys and heart-attack-level blood pressure (185/130). At Mount Sinai Hospital, my doctor’s fears were confirmed in a matter of days: My kidneys were irreparably damaged, an ‘‘uncommon but not rare’’ side effect of long-term lithium use. I was told I could phase out lithium and start another medication, or face dialysis and a kidney transplant in 10 years.

It doesn’t really feel like an obvious choice; it just feels like two bad options. Switching meds might mean the return of cornrowed, Eminem-obsessed Jamya and many seasonal gourds. Yet tubing up and cleansing my blood until I get a stranger’s kidney quilted into the rest of my insides is hardly more appealing. Test results indicate that my kidneys are working about half as well as they should; Maria DeVita, a nephrologist at Lenox Hill Hospital, told me that if I am to switch to preserve the kidney function I have left, ‘‘the time to strike is now.’’

Wishing her luck coming off, and I hope it turns out that there is a third and fourth option that work as well for her.

Wednesday, June 24, 2015

He's still just like someone without mental illness, only more so.

I wanted to share this wonderful essay with you.  It's by Mark Vonnegut, and you may remember the review I wrote and how I loved his memoir, Just Like Someone Without Mental Illness, Only More So. 

This is an essay posted on KevinMD, "A doctor shares his story about overcoming mental illness"  and do surf over to read the whole thing. I promise you'll be moved.  

Here's a part of Dr. Vonnegut's writing: 

In my career as a mental patient, I started with schizophrenia, worked my way up through manic depression, and have now settled at bipolar disorder. I can joke about it because I recovered sufficiently to get into and through medical school, internship, and residency, and have had the enormous honor and privilege of being trusted by parents to help them and their children. I make no bones about it; I make mistakes just like everyone else, but am very proud of how well I do my job.

I’m also very aware of how easily I could have ended up otherwise — a suicide statistic or just another broken young man who never got well enough to have a life.

The diagnosis doesn’t matter much. What they think you have can give doctors a clue about what to do or not do, but for the person who is suffering, and for those who love him or her, wanting the pain and trouble to stop is enough. Knowing that others have recovered is very helpful; most patients, including myself, have diagnosed themselves as hopeless more than once.

He goes on: 

The reverse is also true; just because you don’t hear voices, doesn’t make you a model of mental health. One of the problems with mental health diagnosis is how reassuring the process is to “so-called normal” people. The sub-text to me having a thinking disorder is that your thinking is fine. I freely admit that I have an affective disorder, and find the idea that my feelings are more than a little off-base a huge relief — but to jump from my affective disorder to the conclusion that your feelings make perfect sense is just illogical.

There are all kinds of statistics, but the bottom line is that no one among us is 100 percent crazy, and no one is 100 percent sane. The chance that you or someone you love won’t need help at some point with what we broadly call “mental illness” is 0.

And finally:
There ain’t no difference between them and us. We’re all here to help each other through this, whatever it is.
There’s almost always something positive you can do; the problem is believing in that possibility, and letting others help you figure out what it is.


Tuesday, June 16, 2015

Join Us at 9 PM EST for a Tweet Chat on Social Media in Medicine

Dr. Margaret Chisolm was the recent guest editor for International Review of Psychiatry's edition that was devoted to social media in medicine.  The issue is open at no cost for the month of June and the Shrink Rappers all contributed--

Tonight, some of the contributors will be involved in a Tweetchat on the uses of Social media in medicine.  Do join us:

2h2 hours ago

Monday, June 15, 2015

Dressing the Part


The New York Times has a rather interesting opinionator piece by Dr. David Hellerstein called "The Dowdy Patient."  Hellerstein talks about the frustration of treating a lovely woman who longed for a relationship but was notably 'dowdy.'  I'm chopping pieces from Hellerstein's essay below:

A boyfriend, then marriage, and soon after that, kids — that was pretty much all that Greta felt was missing from her otherwise enviable existence, which included Ivy League degrees, a Wall Street career, a downtown loft....

For more than a year, Greta and I met once and sometimes twice per week for psychotherapy and medication treatment....The only area of her life that didn’t improve was romance. Not that she didn’t go on dates, but they typically were one-off events. There never seemed to be a spark, much less a flame.

One day, after a bit of hemming and hawing — I knew it would be a sensitive topic — I raised the obvious: Had she considered getting a makeover? One of her friends, as Greta herself had told me, had recently seen an “image consultant” who recommended a whole new wardrobe, new hairstyle, different makeup. Could that, I asked, possibly be helpful?

Years of psychotherapy training had given me no guidance in how to deal with the staunchly dowdy patient.

But advice about the patient who refuses to be attractive? No.

Maybe a female or gay male therapist would have had an easier time addressing this topic with Greta. But for me, as a straight male working with a straight female patient, every option seemed blocked. Basically, no matter how I tried to put it, I would be saying, “I find you unappealing.”
Which, at least to Greta, would have raised the reasonable question, Why on earth would she want me to find her appealing? The whole thing reeked of grossness.

Psychotherapy is about helping people to see the patterns in their life so that they can make changes.  But it's not about telling people they look awful.  And just the thought of a male psychiatrist telling a female patient to have a make-over makes my skin crawl.  Indeed, it reeks of grossness.  Of note, the first time that Hellerstein brought up the idea with his patient, she stopped him in his tracks -- she told him she dresses up to go out on weekends and her friends say she looks great.

I wanted to write about this, however, because I could relate to Hellerstein's frustration.  I don't have a dowdy patient, but I felt  Hellerstein's awkwardness and difficulty bringing up the elephant in the room --the elephant that seems to exist for one person, the therapist in this case.  While I don't have a dowdy patient, I have had patients whose issues-- whether inappropriate attire or inappropriate anger -- have clearly gotten in their way. For example, one man always wore very dark sunglasses inside and didn't understand why people wouldn't talk to him at social events (remember, somewhat confabulated here) then dismissed my concerns when I suggested that maybe people would like to see his eyes. 

 In these stories, it's really not a therapist's job to say "Have you considered deodorant?" or  perhaps dressing like the person you want to be (employed, sexy, respectable) -- these are things people should hear from friends and relatives, and the truth is that they've all heard it, and often it seems they just don't want to believe that it's actually part of the problem.   And since therapy isn't about having someone scream at a patient that it really is the dowdy clothes sending the wrong message ---(and perhaps the patient does look great on dates and the dowdy clothes aren't the reason for the lack of relationships....), well...these things...be they dowdy clothes, or an off-putting personality trait that the patient doesn't want to acknowledge...make for tough times in psychotherapy.


Sunday, June 07, 2015

Is Psychiatry Monolithic? Can You Rule Out Mental Illness By Reading Someone's Journal/Sketchbook? And, The Murphy Bill Returns

A few things from around the web:

In The Myth of Monolithic Psychiatry, Dr. George Dawson takes on the question of "Is Psychiatry Monolithic?"  I didn't know what that even meant, but now I do, and this is a terrific piece and well worth the read.

Over on the Marshall Report,  former APA president Jeffrey Lieberman gives his opinion on the notebook the Aurora shooter mailed to his student counseling center psychiatrist before he killed innocent people in a movie theater.   Based on his review of the notebook, Lieberman was able to conclude:
His chief complaint and reason for seeking help at the university health center was related to interpersonal issues and anxiety. He does not reveal what would be considered psychotic symptoms. The major issues are his alienation, disaffection, isolation, fear and anger. No mental disorder is clearly apparent. 

Wait, do psychiatrists do that -- rule out the presence of a mental illness -- without so much as meeting the patient?  I guess I missed that part of training.   I'd also like to add as an aside that while I have no idea if the shooter had a psychotic illness or was responsible for his actions (alas, I've never met him), I do think that intense psychic pain should fall under the rubric of what psychiatrists treat even if the symptoms don't add up to meet the DSM Chinese menu criteria for a specific mental disorder. 

And the text for the 2015 version of the Helping Families in Mental Health Crisis came out on Thursday.  The text of the new congressional act is 173 pages long, nearly 40 pages longer than the last version.  Pete Early did a stand up job of getting right on it and comparing the new bill to the 2013 text in  Murphy Introduces Revamped Bill.  Outpatient Commitment is apparently no longer required, but states who adopt it will get extra funds, which I guess I find less objectionable, sort of.  And there are some limitations on ending privacy rights for psychiatric patients which I think might do a better job of serving the intent of loosening these requirements.  I'm still not a fan of singling out psychiatric patients as the only people who can't instruct a doctor not to release information about their care.  And finally,  I'm not sure how Murphy is planning to make more psychiatrists -- our field is already in a shortage situation, and psychiatrists are aging out of the field, with the majority of psychiatrists who are currently in practice now being over age 55.  Personally, I think the only way to get more people into the field is to subsidize medical school for those who go into the field.  As it stands now,  many medical students just can't take on the astronomical educational debt and still manage on a psychiatrist's pay.  

I'm still not sure I support the new version (Oh, I haven't read it and don't know if I will) but this does seem better.  Do check out Pete's post.

And to those who've commented on our decreased rate of blogging, rest assured that we're making good progress with our upcoming book on involuntary psychiatric treatment.


Tuesday, June 02, 2015

Medicare Spending on Mental Health is Up! And Why is This a Surprise?

In today's edition of USAToday, there is an article titled Mental Health Spending is Up, New Medicare Data Shows.  

The article notes:
Medicare providers got more for mental health and specialty care including sports and sleep medicine in 2013, according to new payment data released Monday that shows which healthcare providers received the most money.
Among the biggest changes:
• Spending on psychiatry was up 9.3%, to $853 million

Okay, so I want to point out that in 2013,  psychiatry changed how we code and there was the introduction of new CPT codes.  At the time, the complexity and absurdity of breaking down minute-by-minute break down of each session into psychotherapy versus evaluation/management seemed absurd, but we all eventually fell into breaking our appointments down into a set of codes that captures what we do.  It meant that bills sent to Medicare reflected an E/M portion plus a psychotherapy portion, and the result was a much higher amount that could be billed/charged then under the old "50 minute psychotherapy with medication management code."  

So if you suddenly increase the amount that a service is compensated, why is it surprising that mental health spending went up?  Just sayin' .....