Saturday, January 30, 2016

Guest Blogger Dr. Mark Komrad on Evidence-Based Medicine and Clinician Experience

In my last post- Medications, Parrots, and Crazy Virginia Laws --, I talked about Robert Whitaker's post on Pete Earley's page.  I put a link to Pete Earley's blog, but not my Shrink Rap post, up on my personal Facebook page.  Now some of my Facebook friends are psychiatrists, so this turned my Facebook page into something of a blog post, with no cute animals.  You followed all that, right? (It's some weird version of social media hell, and yes, I tweeted it as well).  The commenters there gave me permission to put their responses as comments on Shrink Rap, but Dr. Mark Komrad's response exceeded the character count for a blog comment, so I'm giving him a guest post slot here.  Dr. Komrad is the author of You Need Help! an excellent book on how to get a loved one into treatment. His response is below:

Friday, January 29, 2016

Medications, Parrots, and Crazy Virginia Laws

For today's post, I'd like to send you around the web.

First, Pete Earley has a piece up by Robert Whitaker of Mad in America. Whitaker clarifies his position on antipsychotic medications and how their use should be avoided or minimized  in Robert Whitaker Explains his Research after being Pigeon-holed as Anti-Medication.  Let me add my bias: I didn't like Whitaker's book Anatomy of an Epidemic where he concluded that anti-psychotics cause psychiatric disability.  His point was correlational -- as anti-psychotic use went up, so did SSDI (government disability) claims. It's not that easy -- there are other factors that contribute to disability claims including financial & social incentives and the acceptability of being on SSDI.  After you read the post on Pete's blog, I'd like to make two points:

~I don't think that it's controversial that people should be on the lowest possible dose of medications --any medications.  Unfortunately, in psychiatry, we figure out the lowest dose by dropping the medications until someone gets sick.  It's not benign, with each small drop in dose there is some risk that a person will end up psychotic, in the hospital, or unable to function, and recovery can take months or more.  So when someone is doing well, working and involved in meaningful relationships, it's not a low risk issue to drop medications.  If they are having side effects, it's a lot easier to take this risk, because at least you're addressing a problem.  This stuff is not easy when you're talking about real people.

~I remember life before the second generation antipsychotics.  Patients hated taking Haldol and Prolixin and Mellaril and Stelazine.  They were very articulate about how miserable the side effects were, and I don't recall anyone saying that patients wouldn't take Haldol because they had "anosognosia" (ah, we didn't have that word then).  Psychiatrists were well aware that patients didn't take the medications because they made them feel like molasses had been poured into the crevices of their brains, or worse.  Second generation antipsychotics may be no more effective, but they are more acceptable to many patients.

Having said all that, Whitaker may be right that people do better with less medicine, either because those who aren't as sick don't need as much medicine and may be able to completely stop, or because the medications sensitize people and make them worse (I have no answers here.)  When someone is psychotic and suffering, this isn't all that helpful.  I wish we had better answers. Whitaker, and others point to Open Dialogue as a panacea, and it may be a better way with better results -- not much of it is controversial, just expensive and it requires resources for immediate response that we don't seem to have in this country.  There are 5.5 million people in Finland and 321 million people in the US, so the issues are different, and people in Finland get hospitalized and disabled, too. 

While I'm pointing you around, Alex Langford does a nice job of discussing Open Dialogue with all it's pros and cons on his blog Here.  Well worth the read. 

You've heard of Creigh Deeds? He's a Virginia state senator whose very ill and very dangerous son was released from an ER because of a quirk of Virginia state law that said if a bed could not be found within 6 hours, then a patient must be released.  Tragedy ensued -- Gus Deeds repeatedly stabbed his father and then died of suicide.   Over on Clinical Psychiatry News, I explain the idiosyncrasies of Virginia law that could allow such horrors to happen.  See Understanding the Deeds Family Tragedy.


And for the latest news in schizophrenia research, here's a study in Nature that's making headlines everywhere.  If I could understand it, I'd explain it to you.  Maybe Roy could drop by for this one? We haven't seen him for a bit.

Lastly, I'll include a link to an article about PTSD and parrots.  ClinkShrink likes birds, and she loves parrot jokes, so please do share yours.  What Does a Parrot Know About PTSD?


Thursday, January 21, 2016

No, You Don't Need Psychotherapy

Dr. Michael I. Bennett had a opinionator piece in the New York Times a few days ago that made my blood boil.  In You Are Stronger Than You (And Your Therapist) Think,  Bennett talks about a patient who has been in weekly psychotherapy for years until the insurance company decides that the patient does not need weekly sessions -- 12 sessions per year are approved.  But the patient is not Bennett's patient, and he writes from the perspective of someone who has worked for an insurance companies. 

Bennett writes:

I know what it’s like, as a psychiatrist, to feel that your patient’s safety depends on your availability to provide emotional support. However, I also know from experience that patients usually survive our vacations, unavoidable short-notice absences and cellphone failures without actually falling apart. Certain patients feel very vulnerable, needy and worried about abandonment, but they feel that way long before we start treatment and, usually, those feelings don’t change in response to treatment. Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be, or as we experience it to be.

If weekly therapy does, indeed, have only a limited potential to heal and protect, then our patients must be stronger than they, and we, think they are. We know that depression and anxiety routinely distort our ability to think realistically by making us see nothing but our faults, failures and worst-case scenarios. When we’re sure that things will fall apart if weekly treatment isn’t readily available, we may well be accepting and stoking this distortion and, inadvertently, helping our patients believe that they are as weak and helpless as they feel.

Depression and anxiety, Bennett explains, can make some people feel like they can never be strong.  He goes on to advice:

My advice to my colleague was to make a list of the patient’s strengths and encourage her to review what she had learned from the tough experiences that she had endured and survived. It would be normal for her to fear the worst from the coming transition in treatment, but this was also an opportunity for her to see through the negative distortion caused by that fear, review her resources and prepare plans for managing whatever worst case scenarios she could imagine. My colleague could assure her, of course, that emergency care was available. But he could also express confidence in her ability to use what she had learned in their work together to survive and thrive, in spite of her doubts and fears — and of his.  

Where, oh where, to begin.  To contain my urge to rant and ramble, I'll hold my analysis to a few bullet points:

  • Obviously, Bennett may be right that therapy may foster dependence.  The therapist may be financially motivated to patients coming frequently, and there are patients who could be seen less often then they are.
  • So how do we determine how often a patient should come?  The therapist & patient in this case say weekly; the insurance company says monthly.  Why 12 appointments?  Why not 11 or 13? Or 17? Or 9?
  • What is the goal here? Is it to find that absolute minimum number of appointments that the patient can tolerate without another serious suicide attempt (as this patient had)?  Without hospitalization?  With medication? Without a recurrence of symptoms? (Which Symptoms?)
  • Is dependence bad?  What if one hour a week of "dependence" and any accidental psychotherapeutic work that happens to happen along with that dependence comes with the the trade-off is able to live life more fully and productively?  
  • "Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be, or as we experience it to be."  Excuse me??? Oddly enough, it seems to me that the therapeutic relationship is often quite helpful.  
  • Might I add that very few patients continue for an extended period in weekly psychotherapy -- it's expensive (even with insurance there are deductibles and co-pays), and time consuming.  There is some automatic self-selection here that leaves the most vulnerable and distressed of people who even want this.
  • Okay, so what do we think about someone from an insurance company who has never met a patient, and generally hasn't reviewed their history and medical record,  should determine how much treatment they need?  Oh wait, managed care has been around for a while.  Now whose idea was that?
Your thoughts?

Tuesday, January 19, 2016

Drowning Bunnies

There was an interesting article in the Washington Post today about a new college president, brought in from the private sector to help a college flourish, who spoke on increasing retention/graduation rates.  In an article provocatively titled "University President Allegedly Say Struggling Freshman are Bunnies that Should be Drowned" (okay, it got my attention), Susan Svruiga writes:

Amid a conversation about student retention this fall, the president of Mount St. Mary’s University told some professors that they need to stop thinking of freshmen as “cuddly bunnies,” and said: “You just have to drown the bunnies … put a Glock to their heads.”

Simon Newman was quoted in the campus newspaper, The Mountain Echo, on Tuesday, in a special edition that reported the university’s president had pushed a plan to improve retention rates by dismissing 20 to 25 freshmen judged unlikely to succeed early in the academic year. Removing students who are more likely to drop out could hypothetically lead to an improvement in a school’s federal retention data; the deadline for submitting enrollment data is in late September.

Newman, a private-equity chief executive officer and entrepreneur who was appointed president of the private university in Emmitsburg, Md., in 2015, said Tuesday that there are some accurate facts in the Echo story, but “the overall tone of the thing is highly inaccurate.”

Oy.  I don't know what President Newman's issue is that he talks about drowning and shooting bunnies, but I since I don't know him --and would like to keep it that way-- I'm going to refrain from commenting on the judgment of the president of a religious educational institution who uses such harsh, violent, and vivid metaphors for talking about those he's entrusted to educate.  

So I'm not sure this is a psychiatric issue,  but I want to comment on the wisdom of weeding out freshmen who are doing poorly in their first month of college.  If one could tell within weeks of their arrival on campus who is definitely not going to make it to graduation, then I would agree with Dr. Newman's concept, but let me use my own language.  If you know for sure that someone is not going to be able to graduate from college, then you would do them the kindest service by not accepting them into your university to begin with.  If you did make a mistake and accept someone who obviously cannot succeed, then it may be best to help them exit early.  College is not for everyone, and if you're never going to graduate, then it may be better to forgo the expense, the debt, the years of struggle and discouragement, the lost income and lost opportunities to master other skills.  Of course, this could be wrong; someone who never graduates may learn incredibly useful things -- both in classes and in the struggle-- and may form invaluable friendships and networks.  Bill Gates didn't graduate from Harvard. Steve Jobs dropped out of Reed.  They did okay without the sheepskin.

Even if it's not all about the diploma, the fact is that the first semester of college is a very stressful time.  Teenagers are leaving home for the first time, they have to wake up and get to class without alarm-clock Mom, perhaps after late nights up using their newfound freedom to discover substances or the opposite sex.  They may not have a sense of how much they need to study, and some may be up far too late pounding at the books, or simply worrying.  Others have to work to get all the bills paid, and figuring out the work/college/social aspects of school may be quite hard.  Some college freshmen get homesick.  Some become ill with serious psychiatric disorders.  But even the smartest, healthiest, and most driven of students may struggle that first semester in college.  Since college is about educating people, it does seem that some tolerance of these difficulties is needed.  From what I can tell,  the predictive value of that first semester is not terribly good.  I've heard stories of kids who've had any number of  issues and terrible grades, who have then gone on to do well.  It may not have been a smooth ride, but it was one that got finished.  

I vote for coddling the bunnies for a while, at least while they get through the transition of separating from their families and figuring out their new environments and its demands.   And you know, I don't think glocks are the answer to very much, and I'm all for a kinder, gentler world.    

Monday, January 11, 2016

Why Can't We Get Help?

On January 8th, Bloomberg Business ran an article on how law students are reluctant to get treatment for psychiatric problems and for addictions. It's not that law students don't suffer from these problems; in fact, surveys show they do in significant and increasing numbers.  Natalie Kitro writes:

People preferred to leave their illnesses untreated than risk not becoming a lawyer. More than 60 percent of students said they didn’t get help for their reliance on drugs or alcohol because they were worried it would affect their career prospects or their chances of getting admitted to the bar. Before they can practice law, students have to pass a “character and fitness” screening, in which officials look into their personal histories with the aim of rooting out people who are too morally compromised to serve clients. The American Bar Association says potential red flags include “drug or alcohol dependency” and “mental or emotional instability.”

Law schools have tried in recent years to convey that students will not be penalized for admitting that they’re suffering, but the report suggested that the efforts haven’t gone far enough. It is tough to counter what the study characterized as a deeply rooted culture of fear in legal education that discourages students from admitting weakness. 

So much for our legal colleagues.  Today,  Dr. Aaron Carroll has a compelling article in the New York Times about why doctors don't get help for psychiatric disorders. "In silence is the enemy for doctors who have depression," Carroll courageously starts by talking about his own episode of illness.  Carroll notes:

Last month, a study in the Journal of the American Medical Association reviewed all of the literature on depression and depressive symptoms in resident physicians — those are doctors still being trained. They found more than 50 studies on the subject. Research shows that almost 30 percent of resident physicians have either symptoms or a diagnosis of depression.

He goes on to postulate:

What makes this all worse is that medicine is a profession in which admitting a problem carries a stigma that can have more impact than in others. A study published in 2008 surveyed physicians in Michigan, asking them about their work experiences and if they had depressive symptoms. More than 11 percent reported moderate to severe depression. About a quarter of them reported knowing a doctor whose professional standing had been hurt by being depressed.
Credit Jody Barton
Physicians with moderate to severe depression had a decrease in work productivity and job satisfaction. They were also two to three times more likely to say that they were worried about, or had difficulty getting, mental health care. Although the Americans With Disabilities Act, passed in 1990, prohibits employers from asking broad questions about illnesses when people apply for jobs, state medical licensing boards still ask specific questions about mental health.
Because of this, physicians are much more likely to avoid treatment. They’re also more likely to self-medicate.

Sometimes that medication is appropriate, as with anti-depressants. Often, it is not. A 2012 study in JAMA Surgery found that more than 15 percent of the members of the American College of Surgeons had a score on a screening test consistent with alcohol abuse or dependence. Among female surgeons, the prevalence was more than 25 percent. Those who were depressed were significantly more likely to abuse or be dependent on alcohol.

And if that's not enough, two weeks ago, KevinMD ran an article called "Don't poop wher you eat: Mental Health Services for Young Physicians".  Amy Ho talked about insurance requirements that residents in training often must get health care --including mental health care -- at the institutions where they work.   Ho talks about the 29% of residents who are depressed, and the reality of seeking mental health care at an institution where you work:

While privacy protection acts like HIPAA are real, they are difficult to trust when you know every single one of your co-workers and ancillary staff (nurses, attendings, etc.) have a password into your private file. Further, unrelated medical care (for example, an ER visit during work hours from a needle-stick accident) allows completely HIPAA-compliant access by one of your coworkers into all of your records.

There is a saying, “Don’t [poop] where you eat” — that is, to keep personal and professional separate. For many residents whose health care is limited only to their place of work, there are often no other options. Of depressed first-year residents, over half cited “perceived lack of confidentiality” as a barrier to treatment.

So I'd like to suggest that these issues of stigma have gotten worse, and not better.  When I was a medical student at an institution with a strong psychoanalytic bent, entering psychotherapy was considered part of what one did to get to know yourself better: essential if you were going to be a psychiatrist, but also not shameful if you believed the unexamined life was not worth living.  People talked openly about being in therapy.  The chief resident in psychiatry put his analysis schedule on the unit bulletin board (times not to disturb him).  A cardiologist told me he wanted to be a psychiatrist until he went into treatment and realized he only wanted to deal with his own issues.  People openly talked about going to therapy.   One of my classmates had a very serious suicide attempts -- it wasn't widely known, but I asked her roommate where she was headed one evening and the answer was to visit her in the ICU where she was on a ventilator.  I don't know what transpired from there, but I do know she wasn't kicked out of medical school--as she might have been today-- and she went on to graduate on time and to obtain a very competitive residency slot. It's not that it was such an ideal world -- many people at my undergraduate school died of suicide and I don't know if those people were in treatment or not. But in some circles, there was less concern with secrecy and stigma.

I believe that certain behaviors have always been, and always will be, stigmatized.  When your mental illness leaves you to suffer quietly, the problem is yours, and if we hadn't come to associate "mental illness" with mass murder, and the possibility of unpredictable, disruptive behaviors, if we didn't erode privacy with records in the cloud, and if we didn't make it so damn difficult and expensive to get good treatment,  then there should be no shame for seeking treatment for depression, anxiety, or even most substance abuse problems.  I'm not sure our society has ever been comfortable around florid psychosis, nor do I think it ever will be.

Okay, hold with me for one more article.  In yesterday's Washington Post there was the story of the Dallas District Attorney who's position was being threatened because she disappeared for a couple of months to get inpatient treatment for depression, and had been treated for substance abuse.  But this DA's illness was, per the media, not just about her own personal suffering.  In a paranoid state, she fired  colleagues, she was obviously intoxicated at work, and her illness left her impaired and made life difficult for others, until she got treatment and recovered.  A judge dismissed a lawsuit to oust her. I wish her all the best moving forward.  One might hope, however, that people in such powerful positions might feel it's safe to get help before their problems effect others. 

Tuesday, January 05, 2016

Is Everyone Mentally Ill?

We talk about mental illness based upon a standardized set of symptoms, where the symptoms co-occur in groups/clusters/syndromes in ways that enable us to cluster them together (i.e. make a diagnosis), treat the illness we've defined, and have some means of predicting outcome (i.e. 90% of people will have full remission of their symptoms within 6 months).  We talk about these clusters of symptoms as being illnesses or disorders, and we look for biological correlates -- changes in brain chemistry, anatomy, metabolism -- to divide those people who have the disorder from those who don't in the hopes that someday we will have tests to tell us who will respond to various treatments.  It would be very nice to get rid of all this trial and error medication cocktail stuff and just have a test that says "Meds won't work for you, you need TMS," or "no point in using an second generation antipsychotic, go straight to clozapine."  So far, no great breakthroughs in terms of either diagnosis or treatment predictability, but give it time. 

So there was an article in the New York Times on January 2nd titled "Is the Drive for Success Making Our Children Sick?" Vicki Abeles talks about how childhood stresses lead to illnesses, including ulcers, as well as more medical illnesses as children age into adults.

Abeles writes:
STUART SLAVIN, a pediatrician and professor at the St. Louis University School of Medicine, knows something about the impact of stress. After uncovering alarming rates of anxiety and depression among his medical students, Dr. Slavin and his colleagues remade the program: implementing pass/fail grading in introductory classes, instituting a half-day off every other week, and creating small learning groups to strengthen connections among students. Over the course of six years, the students’ rates of depression and anxiety dropped considerably.

But even Dr. Slavin seemed unprepared for the results of testing he did in cooperation with Irvington High School in Fremont, Calif., a once-working-class city that is increasingly in Silicon Valley’s orbit. He had anonymously surveyed two-thirds of Irvington’s 2,100 students last spring, using two standard measures, the Center for Epidemiologic Studies Depression Scale and the State-Trait Anxiety Inventory. The results were stunning: 54 percent of students showed moderate to severe symptoms of depression. More alarming, 80 percent suffered moderate to severe symptoms of anxiety.

“This is so far beyond what you would typically see in an adolescent population,” he told the school’s faculty at a meeting just before the fall semester began. “It’s unprecedented.” Worse, those alarming figures were probably an underestimation; some students had missed the survey while taking Advanced Placement exams.

Okay, so wait, at least half of a group of students surveyed were moderately to severely depressed (?what about mildly depressed), and 80% were moderately to severely anxious?  And the symtptoms abated when the stress disappeared?  This doesn't make sense -- are our disorders illnesses --- brain diseases (as some like to call them)-- or are they part of the spectrum of normal reactions to stress, pressure, and likely lack of sleep? 

In a clinical setting, I'll tell you that sometimes it feels really clear cut: there are people who get sick and they get severely psychotic, or they markedly change from their usual personality. They shut down and lose their usual vitality and ability to function; they aren't showing up for those AP exams.  They become so symptomatic that they become someone totally different, and there is no 'hiding' their illness.  In other cases, it's not so clear cut -- people come in complaining of symptoms of depression, loss of interest, sleep changes, libido changes, suicidal thoughts, and any mix of symptoms that meet criteria for a disorder, and they attribute their distress to a given set of life circumstances.  But they're functioning in their usual roles,  and they are able to mask their symptoms: the rest of the world may not know how badly they feel.  If they are coming to see me as a psychiatrist, they often want medications, and medications often help.  Would they need medications if we could remove the stress?  Often they say 'yes' but we can't make that happen.  Maybe you're thinking about school stress and pressure to achieve, but there are other stresses -- illnesses, financial burdens, divorce, family chaos -- which don't go away by dropping a class or giving up tuba. 

If the studies cited above are accurate -- and I didn't look at them -- and the symptoms are persistent, then this doesn't fit with our idea of mental illness.  It comes to be about a normal reaction to stress, a need -- as noted above-- to change our environment, and a question as to what gives resilience to those few who don't have symptoms.