Lots And Lots Of Questions

One of our blog and podcast followers wrote to us with a few questions. I'm not going to mention the person's name without permission, but they're a pre-med student with an interest in psychiatry. I thought I'd take a stab at some of the answers. Dinah and Roy can chime in with their own thoughts on the subjects. Here we go:
Dinah: I'll chime in in green. Roy? Roy? Where are you Roy?

1. Firstly why did each of you choose to go into psychiatry?
Clinkshrink: There were many reasons. I loved neuroanatomy and did well in it. I was a big fan of the "popular science" brain books as a med student--Andreasen's "The Broken Brain" and anything by Michael Gazzaniga. I enjoyed mysteries and "black box" kind of puzzles, and the human mind is the biggest "black box" puzzle in medicine.
Dinah: I was intrinsically interested in why people do what they do and feel how they feel. I'd planned to get a Ph.D. in psychology and do research, and then realized that if I became a psychiatrist, I'd have the option to do both research and clinical work. So why didn't ClinkShrink become a neurologist???
Clink redux: I didn't become a neurologist because gross neurological impairment wasn't interesting but mind-brain issues were. Neurologists don't deal with hallucinations and delusions, usually. There's a big difference between psychiatry and neurology.
Roy:  Please also take a look at this 2007 post, where we also addressed this question in more detail in Who Wants to be a Psychiatrist.  I grew up watching several family members develop hallucinations and behavior changes, questioning how this could happen to someone's mind.  I started out wanting to go into neuroscience research, deciding to go to medical school only to learn more about how the brain and body work together.  I later learned how much I enjoyed helping people with these problems that I decided to go into psychiatry.


2. How do you cope with some of the stupid and strange stuff people say to you? How long does it take to learn to keep a straight face?
Clinkshrink: The "strange stuff" is what psychiatrists enjoy hearing about. Complicated delusional systems can be bizarre and fascinating and I enjoy listening to that. It's not hard to keep a straight face when you know the person actually believes what's happening to them and it's frightening or bothering them. If you put yourself in their mind set and think about what it would be like if your food really WERE being poisoned, or you really did have something implanted in your teeth that controlled your mind, well, that wouldn't be very fun.

Dinah: There were a few times as a medical student when I did want to laugh. I haven't found that anyone says anything I feel is stupid. Sometimes I have have trouble empathizing with peoples' ideas, especially if they are paranoid or are offensive to me. This is unusual, though, and mostly I enjoy listening to stories about people's lives, and nothing about their pain feels stupid or strange. Some of it feels desperately sad.

Roy:  It doesn't feel like coping, it feels like trying to learn how to speak someone else's language, and understanding how they see the world differently from how I see it.


3. Do SSRI's make non-depressed people relatively happy? Do TCAs have any mood altering affect on non-depressed people as well?
Clinkshrink: Antidepressants are mood-correcting rather than mood elevating. There is some research to suggest that SSRI's may make non-depressed introverts more outgoing, and I have direct experience with non-depressed antisocial patients who like SSRI's because it makes them more apathetic and less reactive to minor slights. Dinah and Roy may have other experiences.
Dinah: Many people take SSRI's for anxiety and find them very helpful, even if they aren't depressed. I guess what Clink said. Also, they can induce mania, so theoretically, if someone with no mood disorder takes an SSRI, they could unmask bipolar disorder.

Roy:  While antidepressants can result in a flattening of affect for some (more so for SSRIs than TCAs), at least one study found that nondepressed subjects had a more positive outlook.


3. What is the neurological basis behind the symptomatology in disorders such as depression, bipolar and schizophrenia? Does it explain all the various subcategories assigned to depression and bipolar?
Clinkshrink: This one is easy. We just don't know. In spite of all the research being done in neuroimaging with PET scans and fMRI, we still don't know for sure what goes awry in these disorders, and we can't use these technologies to diagnose or subtype psychiatric diseases.
Dinah: As per Clink: We don't know.
Roy:  I spent three years doing postmortem brain research in schizophrenia.  There are quite a few replicable findings, such as reductions in markers of synaptic connections and fewer numbers of certain kinds of brain cells.  However, we don't know what they mean or how they are associated with symptoms of the disease.  Like Dinah said, we don't know for certain, but there are many good theories.

4. Why and how do some people with depression suffer from psychotic symptoms?
Clinkshrink: See answer #3. There's still a lot we don't know. Some people are genetically predisposed, some people have vascular or traumatic brain injuries that predispose them, some people have overwhelming life events that trigger an event. For me a better question is what makes people so resilient---able to survive horrible childhoods or natural disasters and "bounce back", while others can't handle routine life events without checking in to a hospital.

Dinah: Regarding the question: Great question. We don't know.

Regarding Clink's answer: I agree that their are some amazingly resilient peeps out there. I don't, however, know of people who end up in the hospital because of inability to handle "routine life events." Seems to me that people have episodes of illness....sometimes they identify a precipitant, often they don't, and sometimes I think the search for a triggering event is just a human nature way of trying to explain what may, at this point, be the unexplainable.
Clink redux: Some of my patients with severe ASPD seek admission to hospitals for, by their own report, being "unable to handle life". In other words, having no place to live, no friends or family to help them, and not being able to keep a job. They lack the resilience and ability to maintain the basic necessities of life. Or a girlfriend breaks up with them and they end up in the hospital.



5. What are your views on prevention for psych related problems? How do you think they should fit in a model of public health?
Clinkshrink: This is the next phase of psychiatry---primary prevention. We already have national depression screening day in October, and primary care providers are starting to use simple screening instruments for various psych disorders. All of this is well and good, but it means nothing if everyone can't afford a doctor. Finding the problem is one thing, doing something to solve it is even better.

Dinah: Prevention? We're a long way from knowing how to prevent mental illness. World peace and drug prevention would go a long way towards helping some people to not develop problems.

Roy:  Prevention is the holy grail.  (Insert Monty Python quote here.)


So those are my answers to lots of questions.
And mine, too!

Why Am I Asking All These Questions?

I'm reading a book where the shrinky author starts off with a revelation: it's not the best care to see patients for a 50 minute evaluation, start a medication, have them come back in a month for a 15 minute med check, and refer them to a social worker for psychotherapy. It does sound like a good way to make a lot of money. If you aren't totally exhausted, overwhelmed with the phone calls and paperwork you must have seeing that huge a case load, and are someone who is gratified from this type of work, then it's cool by me. It's not what I want to do.

The author trained at about the same time as I did, and trained at an institution with a biological orientation, like the one I trained out. He talks about this kind of care as though it's standard and the usual and expected. I've never heard this as standard, and in my private practice, I see new patients for 2 hours, and want people to come back weekly for 50 minute sessions until -- they are no longer symptomatic, or they've gotten what they want out of the treatment. Some people come into treatment without symptom---their old shrink moved or died, and they just want a script and someone to rely on if they get sick. I don't insist they come every week, but I'll ask them to come more frequently than they are used to coming for a little while until I feel like I know them. Some people can't afford weekly psychotherapy or find it to be a burden, and I often respect their wishes to come less frequently, unless their illness is destroying their ability to function, in which case I think they need to come weekly. I don't see anyone more than once a week (unless there is an emergency) routinely, and I never seem to have patients who come requesting twice weekly therapy sessions. Almost everyone comes for the full 50 minute session. A few people who just aren't talkers come for half hour sessions.

I've worked in a number of community mental health centers. I know some clinics have huge caseloads and a full-time doc may have 500-1000 patients. I've never worked anywhere like this. Most of the clinics I've worked in have left the frequency of visits up to the doc, though certainly there is a clinic tone. In one clinic I worked in, most patients saw the doc once a month, where I work now, it's once every three months for patients who are stable. The therapist attends those sessions, and they may be quite brief....many of the patients don't seem to want to talk, and the paperwork burden imposed by the regulatory agencies are very heavy. Still, the standard at all the clinics I've worked in is 2 patients an hour. The no show rate is high, and sometimes a 3rd patient may be squeezed into the schedule if there is a scheduling problem.
My record is 15 patients in one day, and this was while I was volunteering at a clinic in Louisiana after Katrina, and the clinic had no full time doctors and a huge demand. It was 15 patients I'd never seen before, some were quite troubled, and it was a tiring day for me. So my hat goes off to those docs who see 4-6 patients an hour. I couldn't do it.

So what is the standard? I thought I'd ask. Of our readers, it looks like many see their psychiatrists weekly and many see them for 50 minute sessions. Just thought I'd ask. Thank you for taking my surveys and please do add your comments.

The Call Of The Wild

Oh deer...er, dear. It's been three weeks since my last blog post. I have a good excuse. I was having fun.

Rushing mountain water is very cold. Standing on the top of a mountain as a lightening storm rolls in is rather impressive. I enjoyed watching a hawk in flight and waking up in the middle of the night as some type of wildlife rummaged through the campsite. I even enjoyed the hailstorm, except for maybe the part about wondering whether the tent would be gone when it was all over. I saw loads of deer (including the one that rummaged through the campsite), a bear (it looked at me and was obviously sniffing for beef jerky. Fortunately I wasn't the one carrying it.), lots of cold rushing water and water falls, and even a skunk (see reduced picture).

My favorite find was this very unusual looking mushroom.

It was huge as well as being a bright yellow-orange color. After a bit of Googling I think I've got it identified, but if any of you out there really know mushrooms and can tell me for sure I'd appreciate it. I think it's a jack o'lantern mushroom (omphalotus illudens) which is known to be toxic. Somehow it seemed rather fitting that poisonous plants should be part of a forensic psychiatrist's vacation experience. There were no historical prisons in the mountains, so I had to find something forensically relevant.

Community in Uproar After California Psychiatrist Fired

This is an interesting story, not because of the controversy of a psychiatrist being fired and the poor communication about her replacement, but because of the way the community has had so much involvement in the discourse about the whole thing, by way of the Comments section of the local newspaper's online version.

Where? SCHC, Redding, California, in Shasta County. Here's the first few paragraphs from the May 2 story in the Record Searchlight:

A Redding health clinic that serves mostly low-income residents has fired one of its two psychiatrists, leaving hundreds of her patients scrambling to find other care.

The Shasta Community Health Center terminated the contract of clinical psychiatrist Lynne Pappas on Friday, Chief Executive Officer Dean Germano said. A former Shasta County psychiatrist, Pappas had been with the clinic for about four years.

Neither Pappas nor Germano would say what led to her dismissal, but patients said they were told by clinic employees that Pappas had been escorted from the building several weeks ago and suspended after an argument with her supervisor, medical director Dr. Ann Murphy. Murphy did not return a call Tuesday seeking comment.

“It’s an employment matter and the only thing I can say is it was just not working out,” Germano said Monday. “I will say Dr. Pappas in my judgment is a fine physician. It has nothing to do with her competency or care of patients.”

What follows the story is more than 60 comments from the community, mostly skeptical about the reason for the firing, suggesting politics or unwillingness of the departing doctor to cut corners.

You should go read some of the comments; it's really quite an outpouring of support for Dr. Pappas and concern for their family member's follow-up care.

California is currently going thru an evolution in forensic mental health care after a recent court order and prisoner class action lawsuits have required the prisons there to increase the wages paid to forensic mental health providers in order to encourage them to take these jobs. As a result, salaries for psychiatrists in West Coast correctional settings have gone through the roof. This has caused some docs working in community clinics and hospitals to play a Go To Jail card, taking up some of these new positions, which had previously gone unfilled. This is resulting in more difficulties in finding psychiatrists and other mental health professionals to fill community positions, resulting in higher salaries being offered, and breaking county and state budgets.

Lawyers for mentally ill prisoners will ask a federal judge today [Apr 23] to force the state to take drastic action to stem a staff exodus from California's mental hospitals that has jeopardized patient safety and left psychotic inmates to languish in jails and prisons without proper treatment. U.S. District Judge Lawrence K. Karlton in February ordered the state Department of Mental Health to formulate a plan to reverse a staff exodus from the state's beleaguered hospitals in recent months. The staff departures occurred after the same court had ordered raises for prison mental health staff that made prison jobs more attractive than those at hospitals. ... "The plan … is akin to placing a Band-Aid over a gaping hole in an almost empty bucket of water, while doing nothing to refill the lost water," lawyers for the prisoners wrote, calling the approach a "wait, see, and hope for a miracle" strategy that "is reckless and must be immediately addressed by this court."

It doesn't sound like this current firing has much to do with these dynamics, but it is important to understand the occupational landscape in CA.

Back in Shasta County, a second newspaper article triggered additional community support and dismay...

Kathryn Ranken, a private therapist in Redding who sees some of Pappas' clients, said it was "unethical" for the clinic to dismiss Pappas without having a plan in place for treating her hundreds of ailing patients.

...followed by yet a third article yesterday...

Pappas wasn't hit by a meteor; she apparently was suspended a few weeks ago after an argument with the clinic's medical director, and she was fired Friday. That left time to make the best of what was bound to be a rocky transition, yet this week the clinic's managers and Shasta County Mental Health were still figuring out how to handle referrals of Pappas' patients.

And we're not talking about just a few people. Pappas and the health center's one other psychiatrist had more than 2,000 patients...

Sounds like Clink's caseload.

It's just really good to see the paper, and reporter Tim Hearden, use Tim's blog as a way of holding a kind of virtual town hall meeting to help resolve this crisis in the community's ability to meet the mental health needs of its members.

(And... this really is Roy... I know the topic sounds real Clinkshrinky.)