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.