PTSD and the Forensic Psychiatrist

 
This blog post is aimed at anyone considering a career in forensic psychiatry. Please read this interview in the Ottawa Citizen entitled 'Tough forensic guy' John Bradford opens up about his PTSD'.

I'm going to preface this post by saying that I know the man featured in this interview. He is an extremely accomplished and internationally recognized authority on the evaluation and treatment of sex offenders. To think that we could have lost him is a devastating idea to me. He has always been respected within the forensic community, but I respect him even more after this interview.

In this article Dr. Bradford talks about the recent stress a pretrial evaluation placed upon him when he had to work overtime, under a deadline, to evaluate a sexually sadistic murderer. He was required to watch actual videos of the crimes, to witness the killings and to hear the pleas of the women he knew were doomed. The experience brought back recollections of other serious crimes and cases he had been involved with in the past. In the interview he discusses the effects this had upon him over time and the challenges he faced when he finally needed to get help dealing with it. Getting treatment was particularly difficult for him, both because of his prominence but also because forensic psychiatrists are just supposed to be able to handle this stuff. In his own words:

“It’s complicated,” he says. “In my case it was macho. I’m a top forensic psychiatrist and I saw it as a weakness. I don’t talk about the treatment much because it’s difficult for me but getting to it early is important.”

I understand completely what Dr. Bradford is talking about here. Over the years, forensic psychiatrists end up hearing and seeing information about crimes that are pretty terrible. We see digital photographs of crime scenes, autopsy photographs, surveillance videos of murders, suspect interrogations, phone call tapes, written letters and other pieces of evidence that relate detailed information about violent crimes. A single case can require weeks and hundreds of hours of study with repeated exposure to horrible events.

Even without developing PTSD this can change your view of the world a bit. At times I joke that when I give directions now I don't use street names anymore, I give directions in terms of crime scenes: "Take a left and drive south a few blocks until you get to the church that was the scene of the ice pick murder, then take a right until you get to the samurai sword decapitation..."

Yeah, it makes life a little weird.

There are prohibitions about talking about active cases, for legal reasons, but there are also good clinical reasons why you don't talk about your cases with friends and family. Once you get these images in your head they don't go away, and it's not fair to place them into the heads of other people. I warn my program applicants about this too.

To a certain extent, medical training weeds out people who aren't able to handle this. I think there's a reason why my medical school put anatomy class as the first class on the training agenda. After four months hanging over a formaldehyde soaked body, it took me a while before I could eat chicken again. The muscle fibers and tendons just didn't look the same after anatomy class.

Some people complete forensic training and never touch a forensic case again and never do forensic work. I've often wondered about that, and wondered what we could do ahead of time to help people decide if they're really cut out for the work. Given Dr. Bradford's interview, we should probably also think about what we should be doing to look after the people who stay in the work.

WhatsMyM3?

NBC-4 News Clip from Doreen Gentzler (May 16, 2012)

What’s your mental health number?

This is the question that the Bipolar Collaborative is asking, using its WhatsMyM3 screening tool [PubMed]. “Many other illnesses have a 'number' that one can track – cholesterol, high blood pressure, diabetes. What’s the number for mental health?” asks Michael Byer, president of M3 Information, based in Bethesda, Md.

~from Clinical Psychiatry News

Today's USA Today newspaper ran a story titled, "Screening for mental illness? Yes, there's an app for that," by Michelle Healy.


WhatsMyM3 is a validated, 3-minute tool that screens for symptoms of depression, bipolar disorder, PTSD, and anxiety, and can be used to monitor changes in symptom severity over time.

One of the developers, Michael Byer, approached me about a year ago for my opinions on development and use of the screening tool. Disclosure: After reviewing the research and seeing how useful it is, I have become more involved in the organization, becoming an adviser to the group that was started nearly ten years ago by past NIMH chief, Robert Post MD. (listen to podcast #63)

It differs from other mental health screening tools, such as the PHQ-9 and the MDQ, in that these are all unidimensional -- they only measure one domain of symptoms. The M3 is multidimensional, measuring four areas of symptoms. Furthermore, when compared to results from the standardized interview tool, the Mini International Neuropsychiatric Interview (the MINI measures for 15 different mental illness diagnoses), WhatsMyM3 provides a total mental health score that is 83% sensitive in finding true positives and 76% specific in finding true negatives. In addition to the total score, there are four subscores, one each for depression, bipolar, PTSD, and anxiety.

Put another way, the negative predictive value of the total score is 89%, meaning that if you score under the threshold, there is an 89% chance that you do not have any mental health diagnosis by the MINI. As with most screening tests, you want the negative predictive value to be high so that you don't have to subject the "negatives" to more specific testing. The positive predictive value, or PPV, is generally lower for screening tests. It is 65% for WhatsMyM3, meaning that if you score positive (total score >= 33 and positive for functional impairment), the odds of you having a diagnosis is almost two-thirds. A clinical evaluation can then help to determine if you do have a diagnosis. (Note: this tool cannot give you a diagnosis; it can only describe your relative risk of having, or not, a diagnosis.)

What people have found to be most helpful is using WhatsMyM3 to monitor their symptoms over time once they do have a diagnosis. This can be done for free on the website, or for $2.99 using the iPad or iPhone apps, or the Android app. For mental health clinicians, they can download the free M3Clinician iPad app and then screen their own patients. For about a dollar per screen, they can register their patients who want to track their symptoms over time and share their scores with the clinician. Primary care providers also purchase screens, and can even obtain insurance reimbursement by billing for an annual health risk assessment. The patient reports can be viewed by logging into m3clinician.com.

A sample report for a fake patient can be viewed here.

I think this sort of tool, or app, is exactly the sort of mHealth thing that empowers consumers to better manage and become engaged in their health care needs. This is happening in other areas, like diabetes, heart disease, and obesity. Mental health is also making great strides in mHealth.

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I should also point out here that the folks at M3 Information were the only ones to take us up on our offer of a free "advertisement" on Shrink Rap in return for donating at least $200 to our NAMIWalk for Mental Health Month (we don't typically accept display ads). A logo ad will be running soon on Shrink Rap soon for two weeks in recognition of their charitable donations. It will look like this and link to the iPhone and Droid apps. [We received no money ourselves from M3 nor from NAMI. We've never accepted any money from Pharma companies, nor does M3.]

Mental Health, Military Style-- Guest Blogger Dr. Jesse Hellman

Today, we're talking about mental health and the military.  But first, I just learned, via Facebook, that today is International Polar Bear Day.  If you have one, hug him tight.  Make sure he's been fed first.


Over on his own blog, Pete Earley, has a post up about a veteran who was about to kill himself with a homemade gun.  He called a Suicide Hotline, the police were sent and the patient was charged with possessing a homemade gun.  It's a good post, worth the read, and Earley brings up issues about mental health emergencies and the legal system that aren't limited to veterans. 


Yesterday, the New York Times had an article about military discharges for a diagnosis of "personality disorder."  The diagnosis is presumed to be a pre-existing one, so once a soldier is diagnosed with a personality disorder, he can be discharged without the usual military benefits.  I know that our guest blogger Dr. Jesse Hellman  has an interest in the topic.  He spent two years as a military psychiatrist, and has attended hearings on the topic, so I asked him to do a quick guest post for us:


Jesse writes:
  The article tells of a 50 year old woman psychologist who enlisted, was sent to Afghanistan, and was involved in a number of incidents, eventually being accused of sexual harassment for remarks she had made. She was sent for psychiatric evaluation and was given the diagnosis of personality order on discharge. There are severe consequences of this diagnosis, which can include loss of future benefits, medical expenses, and more. Was the diagnosis properly considered? Did her commanding officer ask that she be given that diagnosis in order to reduce the huge medical expenses produced by the military?

This is not the first time I had heard of this problem. In the fall, I attended in Washington a meeting of the House Committee for Veteran Affairs. Joshua Kors, a writer who had several pieces in The Nation which addressed this very problem, was testifying along with a soldier who had been discharged as having a personality disorder. The Department of Defense sent several people to testify that there was no abuse of the diagnosis.

One of Mr. Kors's strongest points was the sheer number of personality disorder diagnoses that were being made. It looked like these were occurring at two bases in the United States that processed discharged soldiers: Could it possibly be that this number of applicants slipped through the initial screening process?

My own impressions were mixed. It seemed inconceivable to me that any military commander would directly order physicians to misdiagnose in order to reduce costs to another entity. Vastly too great a risk to him, and to what advantage? On the other hand, the diagnosis as described in the DSM is more severe than the problem warrants: it is possible that many soldiers enlisted thinking the military was for them but then, through various routes, found that life in Afghanistan, under fire, with all the dangers and rigors, was too much. Their attitudes disintegrated. They wanted out. They were poor soldiers who disrupted morale.

To those who understand how to use bureaucracy to effect one's ends, direct orders are not needed. If it takes one hour to examine a soldier and find a given diagnosis, but alternate diagnoses require much more paperwork, repeat examinations, record reviews, etc, and the caseload of the examiner is sufficiently great, is it not predictable that the particular diagnosis that minimizes work will increase in comparison to the alternatives?

So what do you think? There are many issues here worthy of discussion.

I Still Don't Need To Talk

Three years ago in a post called I Don't Need to Talk I blogged about the evidence for and against critical incident stress debriefing (CISD) for preventing PTSD. Back then I suggested that CISD should not be mandatory for people who experience trauma for two reasons: most people don't develop PTSD after trauma and get better on their own even without therapy, and there was increasing evidence to suggest that CISD may make some people worse.

Today a story came across my Twitter feed (thanks USMCShrink!) about the medical response to the Japanese tsunami. Apparently psychological debriefing was strongly discouraged by Japanese mental health authorities for the reasons I just mentioned.

I think this is the leading indicator that attitudes are changing toward the role of psychiatry in disaster response preparedness.  It also may mean that we might have to change how we approach the mental health care of veterans. I've talked to a lot of vets who were required to go through post-deployment debriefing. Did it help? Did it hurt? Are we doing the right thing? While treatment should be offered to people who really do develop disorders, in this case preventive intervention may not be so preventive.

Guest Blogger Dr. David Hellerstein on Trauma and Resilience, Ten Years after 9/11

All New Yorkers have vivid memories of the events of 9/11/2011; and for New York-based health care workers our memories are generally mixed with feelings of frustration and helplessness. We recall how we emptied out hospital beds that day, how we were prepared in emergency rooms and clinics, and how we waited hour after hour—in expectation of a flood of patients that never came.  And we recall how in the ensuing days, weeks, and months, survivors finally entered our offices, clinics and hospitals, seared by memories and nightmares and visions they could not erase.

Patients working on Wall Street, living in Battery Park City or in lower Manhattan, those who were evacuated by boats from apartments located close by the base of the towers, people who happened to be shopping or walking in Lower Manhattan that Tuesday morning, firemen who rushed to the site of the rubble, parents who were scheduled for meetings at Windows on the World restaurant, but had to drop their kids off at school first, people who heard the first impact, and—remembering the prior attack on the WTC—immediately  left the buildings and headed North, people whose apartments were destroyed or cars were crushed or jobs were eliminated…or people who waited in the suburbs for a spouse to return on the MetroNorth commuter train, and finally concluded they would never return.  They all came, looking for help.

We remember equally vividly how many months and years it took for recovery to begin. We worked intensely to enhance the process of recovery, whether through medical treatments or psychotherapy.  All of us, patients and doctors alike, were haunted by the memories of those who never emerged from the rubble, and by the randomness of survival.  And yet we patients and doctors had a unique cameraderie as well—a feeling that we were all in this together, united against a common, though perhaps unseen, enemy.  Surely this helped with recovery, along with the expectation that life would eventually return to normal. 

For neuroscience researchers, the events of 9/11 were a sort of natural experiment, similar to the events of war.  Over the past decade, there has been significant progress in understanding the brain’s responses to trauma and what causes PTSD, and as well as understanding what may help people to recover from such cataclysmic events. It has become abundantly clear that the brain’s fear systems, commonly associated with the center called the amygdala, have incredibly tenacious memories for trauma that are extremely difficult to dislodge.

New research has brought illumination and hope to these issues.  NYU researcher Elizabeth Phelps is doing research on the neurological processes involved in the consolidation of traumatic memories, which indicates that there may be a window of time during which the deposition of such memories can be interrupted. Will this eventually provide a way to prevent PTSD, either by new types of psychotherapy or by the development of new medications that can block the deposition of such memories?

On a broader level, the events of 9/11/2001 have underlined the importance of resilience.  Some survivors of 9/11 quickly returned to their usual level of functioning, yet many others, a decade later, are still haunted by those events.  Resilience, or the ability to survive or even thrive under stress, is being studied as a neuroscience-based process. Researchers such as Avram Caspi have determined that there are genes related to resilience. Other researchers have described behavioral characteristics that are related to higher levels of resilience, such as Charles Nemeroff and Dennis Charney in their book The Peace of Mind Prescription.  (Resilience is one of the 6 key New Neuropsychiatry principles described in my book Heal Your Brain and in my blog at Psychologytoday.com).

Just to mention one key element of resilience: appraisal.  Appraisal means the way in which we interpret events.  If an event is interpreted as a threat, it evokes fear responses, including activation of the amgdala, and a series of physical responses including release of cortisol and stress hormones. Yet if an event is interpreted as a challenge, it evokes a different series of responses, including interest, calm, relaxation, and adaptive coping. And as Nemeroff and Charney note, “The hormones released by an appraisal of challenge include growth factors, insulin, and other compounds that promote cell repair, trigger relaxation responses, and stimulate efficient energy use.”

The components of resilience include:

·      Physical resilience, physical ‘toughening’ and ‘tempering’

·      Psychological resilience “situations are viewed as challenges, not threats”:

·      Activating social networks, including confiding relationships

·      Adequate external supports

·      Challenging one’s self

·      Looking for meaning through involvement

·      Learning

Now, a decade after 9/11/2001, it is possible to have almost a strange nostalgia for that moment, since we live in a world with increasingly huge problems but without clear solutions, in which day-to-day stresses seem to be continually increasing, with worsening financial and political instability, and increased polarization between incompatible world-views.  In attempting to cope with all of these ongoing and much less clearly defined stressors, the question is, what can help?

In my view, resilience is key.

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My Three Shrinks Podcast 52: The Friendly Skies

In Dinah's post Fly Those Friendly Skies she talks about the new FAA policy regarding pilots on antidepressant medication. We found out something about pilot life span. Retired pilots live five years longer than their non-flying peers.

We talk about the New York Times article In Therapy: Cell Phones Ring True. The article discusses what therapists learn about their patients through their cell phone conversations and pictures.

Roy introduced us to the Lanny-yap blog, where we found a picture of Roy's dog, Eddie. This blog has a reference to a Scientific American article on anisomycin, an experimental medication that has been used in rats to wipe out fearful memories. Shades of Eternal Sunshine of the Spotless Mind (2004)!

Finally, we talk about a prospective study of 16,000 adults who started college and tried to guess which psychiatric diagnoses were most associated with failure to complete college. The full study can be found in the April edition of Psychiatric Services.

Once again, we talk about our upcoming book. We still need a title we can all agree on. Help us out by sending ideas to mythreeshrinksATgmail.com!

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This podcast is available oniTunes or as an RSS feed orFeedburner feed. You can also listen to or download the .mp3or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening

Send your questions and comments to: mythreeshrinksATgmailDOTcom

Does EMDR Work?

This is actually Roy's post.

Eye Movement Desensitization and Reprocessing is a technique that is used to treat patients who have difficulties after a traumatic event or events. If you read the wikipedia link, it works. If you ask people, the jury remains out, and the technique has not found a place in mainstream psychiatry. That's not to say that there aren't psychiatrists who do this treatment or who refer patients for it, but most psychiatrists remain skeptical.

Roy was kind enough to do a little research and here's what he learned about the research on EMDR:

A Pubmed search for EMDR and limiting to Randomized Controlled Trials brings up 28 studies.

• 2008 study in BDD showed sig less negative body image in usual tx +EMDR vs usual tx (no placebo comparison).
• 2007 Swedish study in 33 kids 6-16yo with PTSD found sig lower sx. Again no placebo comparison.
• This 2008 Australian study is more interesting, splitting up the therapist's instruction from the actual eye movement behavior. The eye movement was the discriminating factor in producing lower sx of distress. No placebo.
• Van der Kolk's 2007 study of 88 people with PTSD randomly assigned to Prozac, EMDR or pill placebo was quite remarkable, with 75% of EMDR group having long-term relief vs 0% in Prozac group. Again, no placebo control for the eye movements. If we can do sham ECT and sham TMS, someone should be able to come up with sham EMDR.
• This one from Vancouver (from a co-resident of mine from Western Psych whom I would think to be a skeptic) broke out the different types of alternating stimulation, again finding a treatment effect.

Feel free to review the rest of them, but the data so far look promising. I did not see anything about harm from the treatment, so the risk/benefit analysis seems favorable, especially in an individual who has already completed unsuccessful trials of standard treatment.

What's your experience? Please tell us if you're a patient or a therapist who does this, or even if your friend had a good/bad experience with EMDR.

Can We Teach People How To Avoid Mental Illness?

Prevention is an interesting word in psychiatry. It's hard to prevent mental illness-- we believe a lot of it is about genetics-- and when we think about prevention, we think about things like avoiding drugs and excess alcohol, getting enough sleep, growing up in a kind, safe, and loving environment with a reasonable amount of stability. Those are good things. When it comes to preventing Post-Traumatic Stress Disorder, we think about avoiding trauma, to the extent that we are able. Roy has written about the hypothetical idea of giving people medications to prevent the hard-wiring of traumatic memories and we talked about it in our My Three Shrinks Podcast #46 :Fugetaboutit!

But can you teach people not to get ill -- an insurance plan, if you will, or extra-protection-- before they get exposed to extreme trauma? Can you teach them not to get depressed? Not to get PTSD? It's a great idea, but as far as I know, people vary in their vulnerability and resilience, perhaps even tempermentally, and I'm not aware of research that shows you can teach people resilience in the fact of horror. It doesn't mean it can't be done, it just means I don't know of any research proving it. And if you can teach this, I want to be in the class, and I'd like to invite all the folks who live in the inner city to join me.

So Benedict Carey writes in today's New York Times about how the military intends to require emotional resiliency training for every soldier. Wow!

The new program is to be introduced at two bases in October and phased in gradually throughout the service, starting in basic training. It is modeled on techniques that have been tested mainly in middle schools.

Usually taught in weekly 90-minute classes, the methods seek to defuse or expose common habits of thinking and flawed beliefs that can lead to anger and frustration — for example, the tendency to assume the worst. (“My wife didn’t answer the phone; she must be with someone else.”)

Carey goes on to note:

“It’s important to be clear that there’s no evidence that any program makes soldiers more resilient,” said George A. Bonanno, a psychologist at Columbia University. But he and others said the program could settle one of the most important questions in psychology: whether mental toughness can be taught in the classroom.

So what's the downside? I'm not sure there is one-- except the price tag-- $117 million dollars for an unproven experiment? Couldn't we do some pilot studies first? Obviously I'm a bit of a skeptic-- perhaps we can teach people to be more adaptive in mildly stressful places, but I'm wondering if anything shields you from the extremes and the trauma our soldiers experience in combat. Funny to be spending so much for an unproven intervention in an arena where there aren't funds for treatment of those who give so much and come back so damaged.

Shrink Rap: Grand Rounds is up at Health Business Blog!

Check out this week's Grand Rounds by David Williams at Health Business Blog.

Interesting topics include PTSD of being ill, Twitter discussion about remembering doc's instructions, and EMTALA and ER visits.

But I Do Want To Talk

First, Roy wants your opinion about Online Access to Prescription History, so if you haven't chimed in, please do.

This post was inspired by ClinkShrink's post, I Don't Want To Talk, where she discusses mandated debriefing after trauma and what role that might have in either preventing or causing mental illness (Roy: which is what we spent all of podcast #46 talking about).

Disaster Psychiatry is a field that it still defining itself. It's a close-to-home issue for me because Shrink Rap was started as a way for me to deal with some residual angst I had after returning from a couple of weeks in Louisiana where I worked on the Katrina Assistance Project. Roy & Clink got sucked in, but what can I say? At that time, I wrote a piece about my experiences and posted on it's own blog link. I talked a bit about the stuff ClinkShrink discusses-- some history of the Mitchell Model of Critical Incident Stress Debriefing, as well as Sally Satel's paper on how the mental health industry exploited the terrorist attacks of September 11th. You can click HERE to link to my Katrina Reflections.

Since ClinkShrink wants to talk about mandatory debriefing and whether talking about a trauma lessens it's impact and prevents the development of future psychopathology, I'll talk about my own thoughts about the role of psychiatry in the aftermath of a community trauma.You can define community in a big or small way, but I mean a shared experience as opposed to a traumatic act to a single individual .

There are five concerns from a shrink's point of view. There may be more, but these are my random thoughts and it's our blog. Do chime in on the comment section.

• There are people with psychiatric disorders who may no longer have access to treatment-- perhaps because they need to relocate, because their doctor &/or records have been obliterated, their pharmacy closed down-- and they are at risk for a relapse of a pre-existing illness.
  
• There are people who develop psychiatric disorders as a direct result of stress-- it's not unheard of for people to become manic after the death of a relative, to become anxious or depressed, and so if psychiatric symptoms are precipitated without disasters, it's safe to assume they can be precipitated by trauma. Certainly, some of these people may have underlying disorders that would eventually be unmasked anyway.
• There are people who develop psychiatric disorders as a direct result of the specific trauma who may not have ever required the services of the mental health profession if such an event didn't occur. The question here, and the one that ClinkShrink addressed, is whether early interventions to the entire population alter the likelihood that someone will develop a psychiatric illness. Who to target, what to target them with, and if it will matter are all questions to address
  
• There are people who are distressed by an objectively distressing event but who don't (and hopefully won't) develop a psychiatric condition. These people often feel a need to talk and are well-served by friends, family, and religious leaders. The role for psychiatrists here is one that should be taken only if the trauma victim identifies himself as a patient and requests treatment. There seems to be a statement in our society that it's bad to not talk about troubling things-- this is true for some people who feel a need to talk, but it's a blanket statement that often crosses the line into being judgmental.
• Lastly, there is question as to the role mental health professionals should take with disaster workers who go to the aid of the victims. We're back to the Critical Incident Stress Debriefing and I wonder if the issues are different for those who are in the position of being helpers voluntarily (Red Cross workers and assorted humanitarians) versus those who go as a job requirement-- fire fighters and the like. I'm not sure what to say here. Again, this speaks to the issue of interventions to prevent the development of disorder in a population that might remain healthy without intervention.

Ugh, I can't get a picture in. Open all those alligator mouths and yap it up for me.

I Don't Need To Talk

Roy is the blogger who inspired me today. I recently posted about the use of medication to prevent depression, and Roy followed this up with a comment on our Podcast #46 post about willingness to talk and prevention of trauma-related psych problems. He referenced a University at Buffalo study of 3000 9/11 survivors who were asked to respond to an online survey immediately following the 9/11 attack. The survey asked questions about their willingness or need to talk about the event, and followed their adjustment for two years after the initial survey. The study found that those who were unwilling to talk about the event actually fared better over time than those who wanted to talk.

Now, there are a lot of obvious limitations here---and I don't have the actual published article to analyze the news releases' interpretation of the study---but those who responded to the study had not lost any loved ones or known anyone who died in the attack, and it doesn't say whether or not the respondents themselves had direct experience of the event. For all I know, they could have been people living on the other side of the country. Personally, I doubt that people who were really upset and had direct experience of the 9/11 attack would have much interest in responding to an online survey at the time. It also doesn't mention whether or not the people who wanted to talk about their feelings ever actually had the opportunity to do so or received therapy following the event. All of this would obviously make a difference on the outcome.

Nevertheless, I think it says something relevant about an area in which there is a significant body of published data, which is the issue of crisis debriefing counseling. Crisis debriefing is something that's being used for a lot yet it's controversial because its efficacy hasn't been proven and there are some studies suggesting it could harm people.

Critical incident stress debriefing (CISD) was developed with the idea that providing rapid intervention to people exposed to trauma would prevent the development of PTSD. It was used following events like hostage-takings, natural disasters, plane crashes or other mass casualty accidents. CISD uses peer facilitators and mental health professionals in a time-limited, single session group setting to provide peer support and to allow people to talk about their feelings about the event. They also talk about the impact of the event on their relationships or day-to-day functioning as well as coping techniques. In addition to providing an emotional outlet, CISD typically also involves education about stress-related symptoms and stress management.

A PubMed search of the term "crisis debriefing outcome" brings up 33 studies on the outcomes of crisis debriefing counseling. Once you eliminate the studies with no controls and no data, you find that CISD studies have been done on a huge mixed bag of subjects: children, crime victims, soldiers, anesthesia residents, post-partum inpatients, burn victims and emergency service workers. The good news is that the majority of the subjects got better over time, even if nothing was done. The interesting news is that participant satisfaction surveys showed that patients frequently reported satisfaction with CISD, found it helpful and would recommend it to others even though there was no measurable reduction in symptoms. In other words, they felt it was helpful even when there was no objective evidence it helped.

Out of all the studies that reported outcome data in a group-controlled fashion, three found CISD led to improved symptoms. Seven studies showed there was no significant difference between CISD and a control group---neither benefit nor harm. Three studies showed worsened symptoms following crisis debriefing. A couple review articles in the Pub Med search as well as one meta-analysis also showed mixed results, with most showing no clear benefit and a few documenting aggravation of symptoms.

In all, the main conclusion I could come up with from this is that CISD probably should not be mandatory for everyone following a trauma (eg. an employer probably shouldn't mandate that all employees must attend CISD following an episode of workplace violence). It might help some people, and will probably not harm the majority, but a few will be hurt by it. The trick is, you don't know in advance who will fall into which group.

My Three Shrinks Podcast 46: Fugetaboutit!

[45] . . . [46] . . . [47] . . . [All]

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Whoa!  Sorry about the long delay, folks.  In case you missed Podcast #45, with Ray DePaulo, the Chair of Psychiatry at Johns Hopkins, we talked about cosmetic psychopharmacology -- taking psychotropic medications to improve one's mental performance better than one's normal baseline. We then had two related posts, I Forgot (what happens when memory does not work well) and Now I Remember (when people remember too well, such as traumatic memories and PTSD).

The current podcast takes off from there, so you may want to review the above links for, as Paul Harvey would say, "the rest of the story."

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June 1, 2008: #46 Fugetaboutit!

Topics include:

• PTSD. A Psychiatrist Who Learned From Veterans commented that "A really towering paper in the Posttraumatic Stress Disorder literature deals with the excessive stickiness of memory in PTSD. The data comprises case reports of the month long use of Cortisol (Cortef) 10 mg a day, this is a low dose of glucocorticoid, by Amanda Aerni. R Greene at the Dallas VA has a nice paper using rats in a related paper; impressive statistics in the latter." These papers are discussed in the podcast, and mentioned in more detail below.
  
• Cortisol for PTSD.  Amanda Aerni, et al., published "Low-Dose Cortisol for Symptoms of Posttraumatic Stress Disorder" in the August 2004 American Journal of Psychiatry. This was a 3-month observation study on three people with chronic PTSD, using a low-dose of cortisol in a double-blind, placebo-controlled manner. They found "cortisol-related reductions of at least 38% in one of the daily rated symptoms of traumatic memories, as assessed by self-administered rating scales."
• Memory "Erasure".  Wen-Hui Cai, et al., published "Postreactivation Glucocorticoids Impair Recall of Established Fear Memory" in the September 2006 Journal of Neuroscience.  This study exposed mice to a trauma (loud noise).  After developing mousie PTSD, exposure to glucocorticoids at some later time after the traumatic memory is being triggered caused the fear response to be much less.
• More PTSD Talk.  Pink Freud commented that "On the surface, I find the thought of preventing the formation of memories (traumatic or otherwise) to be repugnant. It's experiencing, working through, and ultimately making meaning of what life deals us that defines the human condition."  Here follows lots of discussion about what is a "trauma" (such as being hit by a flying, flaming toilet seat [Youtube] from the space shuttle as in the show Dead Like Me, or being tasered at a political event [Don't tase me, bro]) and how some people are at increased risk for developing PTSD given similar traumas.  Also, discussion about reducing the strength of the connection between a traumatic memory and a pathologic fear response.

• Dinah's Flomax (tamulosin).  Dinah discusses the discrepancy between the focus on benign prostate conditions and other more serious ones.

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Find show notes with links at: http://mythreeshrinks.com. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom). This podcast is available on iTunes (feel free to post a review) or as an RSS feed or Feedburner feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Now I Remember

So in my post from yesterday I talked about the normal process of memory and forgetting. Right after I published that post I started thinking about all the weird little things that I remember.

In order to be a doctor you have to have a pretty good memory. You start out by memorizing muscles and bones and nerves and blood vessels, and work your way into the body by memorizing types of cells and cell processes and biochemical reactions. (How many of you remember how many molecules of ATP are produced in the Kreb's cycle?) The comedian who played Father Guido Sarducci on Saturday Night Live used to have this bit where he'd advertise for the Five Minute College. By sending him lots of money and taking his Five Minute College course, you could get a college degree while learning everything a college graduate remembers five minutes after leaving college.

I'm always surprised by the little factoids and trivia I remember, both in day-to-day life and from college days decades ago. I remember my friend's apartment number because it's the same as the year Jamestown was founded. I remember my childhood phone number (OK, that's an easy one---it's two digits repeated two or three times) as well as the addresses for all the apartments I've ever lived in.

Remembering things too well is rarely a problem for people. When it happens it's usually in the context of unpleasant or horrible memories, memories that intrude on day-to-day life and are upsetting or interfere with one's ability to function, as in post-traumatic stress disorder. These situations are usually managed with therapy, although now people are also experimenting with the use of medications to prevent the formation of intrusive memories after traumatic events. This is still too experimental to be practically useful, however.

Of course, we know that memory is not always a reliable thing. We remember childhood events differently than our older siblings, or not at all. In the 1980's following years of a movement for the treatment of trauma survivors we learned both that bad memories can be repressed, but also they can be created through false memory syndrome. The amazing thing is that false memories can be just as convincing to the individual as real ones.

Speaking of false memory syndrome, here's a practical example. When I started writing this post I was feeling rather pleased with myself that I remembered how many ATP's were produced by the Kreb's cycle. I was wrong. See if your memory is better than mine by checking out this link here.

VA Mental Health Overhaul Sought

Congress and the White House are pushing for reforms in the Veteran's Administration and other military hospitals to overhaul the mental health care provided to people serving in the military -- particularly those coming back from Iraq and Afghanistan -- and those who have already served.

Today's Washington Post states:

Over the past two days, The Post has published stories detailing the bureaucratic and health difficulties of troops returning home with PTSD.
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The Army is hiring 200 more psychiatrists, psychologists and social workers to help soldiers with mental-health problems, and next month it will launch an educational program on stress for all soldiers and commanders, said Maj. Gen. Gale S. Pollock, the acting surgeon general of the Army.

The Army is also expanding a pilot program at Fort Bragg to offer behavioral-health treatment at primary-care facilities to reduce the stigma for soldiers seeking care, Pollock said.

"The tragic cases of combat stress discussed in the Washington Post June 17-18 are powerful and concerning to the U.S. Army," Pollock said in a statement. She emphasized that the Army is continuing to address the problems of soldiers with PTSD, including placing hundreds of mental-health specialists on the battlefield in Iraq and Afghanistan to counsel soldiers with combat stress.

Pollock cited efforts such as post-deployment health assessments, begun in 1998. Based on a 2004 study by Walter Reed researchers, the Army added a second screening for soldiers a few months after their return to catch problems that are not quickly apparent, such as PTSD.
...
Cruz, who helped capture Saddam Hussein, has been plagued by anxiety and nightmarish images of dead Iraqi children since returning home. Yet VA has denied his claim for compensation, ruling that his psychological problems existed before he joined the Army and that he had not proved that he saw combat.

The Washington Post has set up a special online area for this topic, "Walter Reed and Beyond," here.

My Three Shrinks Podcast 1: Podcasting Makes You Potty

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So we finally did our first podcast after talking about it for a month. It's about 25 minutes long and can be found here [this link didn't work using Firefox...I'm working on it fixed]. We couldn't use Shrink Rap for the name, as DrDave is already using it for his psychology interview-type podcast, ShrinkRapRadio. So we came up with this title, My Three Shrinks, with surprisingly little discussion. (Wife prefers the name, Shrinky Dinks, but that makes me feel a bit emasculated. Don't go there.)
Yes, the theme is ripped from the 1960's TV sitcom, My Three Sons, even down to the re-done logo and theme song (Clink wanted us to do Put Down the Duckie, but it just didn't seem to fit in well... maybe in a later one.)

Can you figure out which shrink is which?

So, here are the show notes for the podcast:

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December 3, 2006: Podcasting Makes You Potty

[click the .m4a file to download]

• Tip of the hat to Leo Laporte's This Week in Tech (TWiT) podcast for inspiration
  
• Also a nod goes to Dr Dave Van Nuys at shrinkrapradio.com, who kindly pointed out he was doing a Psychology podcast of the same name way before us. Check it out, it's very well done
• Dr Anonymous is not mentioned even once in this podcast
• 60 Minutes: Beta-blockers to prevent PTSD and reduce traumatic memories?
• Cardiac risk after post-heart attack depression
• Shrink Rap Post: Go Red for Women
• NHSBlogDoc's John Crippen's post about England's idea of requiring psychiatric evaluations for hospice and "assisted dying" patients
  

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[Update: You can now subscribe to My Three Shrinks on iTunes, or download the .mp3] technorati tags:shrinkrap, podcast, psychiatry, psychiatrist, depression, heart, attack, PTSD, propranolol, hospice Blogged with Flock

Clin Psyc News notes: May 2006

• Ritalin patch: I expect to see this a lot in nursing homes. I've seen methylphenidate make a huge positive impact on older depressed folks, and a patch form of administration makes it easier. But, it's another one of those dang off-label issues that's flaring up lately.
  
  
• 4.6% Medicare cuts next year: Will this ever get fixed? Locally, I hear of folks having a hard time finding psychiatrists who will even take Medicare. It used to be one of the easiest to participate with... no multipage treatment plans, etc. But practice costs increase every year, and we cannot make up the difference by seeing more pts (although I hear there have been some "creative" docs who have learned how to squeeze 50 90807s in a 24-hour day... no, thanks).
  
  
• Top 10 Psychiatrist Diagnoses: Something is wrong with this picture. The #1 dx is 296.2 (single episode major depr). I would expect recurrent episode major dep to be #1. And all of "Anxiety states" is only #3? I don't think so. The data come from Verispan's survey of 162 psychiatrists. GIGO.
  
  
• Don't flush your fluoxetine: Says to advise your pts on how to dispose of old pills, but does not say what to tell them. I used to tell them to flush them, but now I say to either return to pharmacy. It seems that flushing has led to high drug levels in the water supply.
  
  
• Prazosin reduces PTSD nightmares: This is new to me. Alpha-1 antagonists apparently reduce sleep problems and nightmares in PTSD. [PubMed]
  
  
• Vivitrol: I saw an ad for this recently approved i.m. form of naltrexone (it was going to be named Vivitrex, but I guess this was too close to some other name). Even if there is some efficacy data, this drug will go nowhere. Why? $695 per injection! Are folks gonna pay $22/day to be sober? It's cheaper to stay drunk! Cephalon blew it. I can only imagine that the market they are going after is the court-ordered treatment market. If they hit that one, they will have a blockbuster on their hands, because it is worth $22/day to stay out of jail. (The number of ad-blogs for this drug are incredible.)