Things That Make Me Crazy

I sometimes think I live in a tight little fantasy bubble where I want life to make sense and be fair.  I want it to be an uncomplicated place where, when resources are limited, we assess the problems and direct the dollars to things we know will efficiently fix the problems.  I'd like us to use our public health  dollars to feed hungry people, to house those without some place warm to stay, to help those in need learn strategies and get jobs so they can help themselves, and to provide health care to those who are ill.  In cases where there are big-picture items that lead to devastating consequences and enormous costs to society, I'd like us to target the causes with early interventions that are known to be effective: so measures to prevent drug/alcohol/tobacco abuse, better and more available drug treatments, and more resources dedicated to early education so that everyone gets the skills they need to earn a living and grow up to be a taxpayer.  

Instead, through some mix of politics and medicine, there are these untested (or poorly tested) ideas out there that cost billions of dollars and money gets diverted away from being used for the direct good of the people.  Maybe I'm wrong-- I'm sure there are plenty of people who disagree with me and think that these changes are important and will make the world a better place -- so by all means, feel free to comment. tell me why I'm wrong, or do add to my list.  It's a little of 'one guy unsuccessfully tried to blow up a plane with his sneakers so millions take off their shoes for screening every day.'  The cost is phenomenal, but I do have to  admit that no planes have been blown up with shoe bombs since, and if my child was on a plane that didn't explode, then the cost to society was worth it, but it's not a very "public health" way of thinking.  But you have to wonder what we're giving up when we put a lot of time, money, or resources towards low-probability events or towards paperwork for the sake of paperwork.  In no particular order:

Dinah's List of Aggravating Diversions from Productivity in 2013

• CPT codes that force psychiatrists to differentiate "medical care" from psychotherapy with rate changes depending on whether the psychotherapy component takes 52 minutes or 53 minutes or the session, and creates 15 different options for coding a single psychotherapy session.
• 68,000 ICD-10 codes for the purpose of diagnosis/billing. Really?  ClinkShrink will be thrilled, code Y92146 is for getting hurt at a prison swimming pool.  Prisons have swimming pools?  And Y92253 is for being hurt at the opera, so Clink and Jesse can both rest assured that injuries they may incur can be coded. This helps us how?  And, no, US prisons don't have swimming pools, but why should that stop us from having codes?
  
• Legislation -- complete with the cost of databanks, means for reporting to such databanks, and the cost of enforcement -- to keep the poorly-defined 'mentally ill' from owning guns when there is no such effort to keep the family members or roommates of those people from owning guns, and there is no such effort to keep guns from those who are known to be dangerous if they are not mentally ill.  The laws in Maryland also include 'habitual drunkards,' -- but there is no provision to report those who goes to detox/rehab or have a second DWI/DUI from having a gun. 
• Continued support of the Second Amendment as interpreted rather widely, despite 40,000 gun deaths/ year, some of them innocent small children. "A well regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed."  I'm just not sure that the founding fathers foresaw a society of drug addiction, rampant suicide, and a country with a firearms death rate beyond any other country in the world.  There was slavery when the second amendment was written, and I don't think the amendment included slaves, so clearly the 'right of the people' did not mean all people, or include assault weapons that did not yet exist.  The second amendment has become an impenetrable devotion -- in Maryland's it's some state legislator's main forum -- as if it were a religious belief.  And people with mental illnesses have taken the blame for all inappropriate uses of guns.  See yesterdays Bloomberg Report for our President's pronouncement, and by all means, read the comments.   
•  Meaningful use -- a government/Medicare phenomena that creates a tremendous amount of work for physicians that does not seem to directly improve patient care (correct me if I'm wrong), and if it does, it doesn't improve patient care/outcomes in a way that warrants the time, and expense.  I don't really know what Meaningful Use is (such details never stop me from ranting), but I know the government will give me money if I'll convert to electronic records and use it in a particular way.  Otherwise, for every Medicare  patient I see, I must charge a lower fee if I don't use e-prescribing (which is not conclusively shown to improve patient outcomes) a certain percentage of the time, and that in 2013, to prevent an drop in my fees, I needed to put a PQRS code on one patient's insurance claim form.  I could not figure out what that meant, so I asked an APA assembly member who runs a hospital.  After two  separate half-hour phone conversations, one in-person meeting, and I have no idea how many hours of his time, he provided me a list of options which included things like "medications not reconciled, reason not given."  I opted to list on one patient's claim a code indicating he was not a tobacco user, and I'm told this was good enough to keep my fees from dropping 1.5% next year.  What's meaningful about this?
• CRISP/Government portals of patient records collected without patient knowledge/permission.  These may be very helpful for emergency care in crisis situation,  and perhaps they allow for data/outcome collection that will be used for outcomes research, but they cost a lot of money and after the NSA scandal, are we all comfortable with the government keeping our health records without our expressed permission?  Are we sure our health information won't bounce back at us in unwanted ways?
• Hospitals that spend HUNDREDS OF MILLIONS OF DOLLARS to replace existing, function, Electronic Medical Records when there are people sleeping on cardboard boxes outside their doors, and when such medical records increase the amount of time clinicians spend with computers and decrease the amount of time they spend with patients -- and don't necessarily decrease medical errors.  This feels wrong to me  on so many levels: there are shortages of physicians and we're diverting their attention to clicking through screens and checking off boxes that have nothing to do with the care of that particular patient, adding hours a day to physician workload, promoting physician burnout, and diverting funds to this project that could be used to pay for health care for human beings.
• Government-run health insurance exchange(ACA) websites that are basically unusuable and create too much frustration for the average person --especially the average person with medical or psychiatric issues-- to work efficiently.  One of my patients was blocked from signing up because he forgot his password, and the recovery question involved his pet's name, only he's never had a pet and was locked out of the system. 
• Hospital medical records that afford no privacy because thousands of people have access to them and patients can not opt out, other than to get care at another institution.  But if you want information about a patient from another institution, with the patient's permission, barriers are put in place to make this next to impossible.  I recently requested records from a local hospital ten minutes from my office, and two weeks later they sent me a form saying that the authorization my patient signed was not good enough, it had to be signed on their specific form.  How crazy is this?  Perhaps it's because that hospital's administrator was so busy looking up my PQRS codes that he wasn't updating their information release policies.
• That my state is proposing to spend money on programs to increase cultural awareness and competency on number of measures when people need food/housing/healthcare/job training.  I'm all for treating people respectfully, but maybe it would be cheaper to fire those who are demeaning to others rather than to set up training programs to make them 'culturally aware.' (Please forgive my cynicism, in a world where everyone is fed, housed, has healthcare, heat, education and jobs, I'm all in favor of programs to increase sensitivity to cultural issues).
• "That my state is proposing to add Assisted Outpatient Treatment (read: forced care) when we don't have enough information to know if this really works without other services in place.  We don't have  enough resources to care for people who want care, and this will entail forcing people to take medications that are known to have detrimental cardiovascular effects in some people,  distressing side effects in others, and may include forcing care on people when that care does not decrease their symptoms. If I thought the legislation was truly about getting care for the very sickest of people -- those 'dying in the streets with their rights on' -- I would be in favor, but I believe it's a "do something" measure to address spree shooters and has been tied to federal funding. 

Thank you for letting me rant.  That's what this was, and I appreciate it.  I feel much better now. 

Meds or Therapy?

It's this funny thing, people talk about the rise in the use of medications like it's a bad thing (and perhaps it is) and the decline of psychotherapy by psychiatrists as also being a bad thing (and perhaps it is).  It's almost like a see-saw, and there is the thought by some that using medicine is a quick-fix, a way of avoiding looking at the more difficult issues that we as humans face in the natural course of human suffering.  It's funny -- as I started by saying -- because it seems like the combination of medications together with psychotherapy  may work best.

Let me address the quick fix thing.  First off, most psych meds take a while to work, they aren't quick fixes.  Second, we've all read that medication helps depression only 30% of the time, or the same rate as placebo, and this  because in clinical psychiatry it often takes a few tries to help someone -- switching medicines, augmenting one medicine with another, or trying some unconventional or creative cocktails. The study looked at a single trial of one medicine versus a sugar pill, not real life psychiatry.  And then we've got that *#$&~ DSM issue which boxes one in, says people have to "meet criteria" as though it's a totally real entity any more than diabetes is (-- see Psych Practice's post on just how scientific the diabetes diagnosis actually is) and there is the implicit criticism that if you take a pill for psychic pain that doesn't 'meet criteria' then it's just WRONG.  Can you imagine if you had a headache and wanted to take an aspirin to stop the pain, but you were told that since there wasn't an anatomical reason for the pain, taking that aspirin makes you a weak pill-popper?     

There are those who feel we should rely more heavily on psychotherapy, as though it's one or the other.  As though we know in advance who therapy will help heal of their mental  illness (we don't), or who therapy will help comfort during a painful journey.  I believe therapy is helpful to many people for many reasons: one is that for some people it provides tremendous insight and relief, though the two are not necessarily connected.  Another, is that by scheduling patient for hour-long sessions, it's so much easier to evaluate and understand them, to know the quirks of their personality and the patterns of their distress in relation to the nuances of their lives, and not just as a checklist of symptoms and side effects taken as independent variables apart from their environment and their perceptions of that environment.  You help them see their patterns, whether it's how they relate to authority figures or how they always feel worse (or better!)  when they stop their medicines.  Finally, when you're on a journey that may be long and painful, it's so nice to feel heard and cared about and like you're a human being whose emotions are important, and not like a person at the deli counter-- #16 today, "I'll have a script for Zoloft  please."    But as a cure, therapy doesn't always work, and we don't have a prescription for how long and how much therapy one needs, or of what type, before we can tell if a trial is adequate.  For medications, there are often some guidelines with regard to dose and time; for therapy there is not.  If you come for treatment of depression, how much therapy is enough to say we've given it a fair chance before adding medications?  Twice a week, 50 minute sessions, for two months or two years?  And what if the patient can't afford the cost of that and wants to try the $4 generic from Wal-Mart?  

So that you know where I stand: if it helps, go for it.  Meds (if the benefit outweighs the risk-- and yes that's important: sometimes the benefit does not outweigh the risk), therapy, light boxes, exercise, ECT, TMS, DBS, acupuncture, yoga, chocolate... I'm all for the reduction of discomfort for those who are seeking it, and I'm all for letting people heal as they will without the judgement of others telling them how to do it right. 

Hmm, I'm not sure what got into me today....

HIP HIP HIPAA HOORAY! Where's My Medical Privacy?

And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets. 
   *       *        *
Today, I"m ranting about medical privacy (now gone) and electronic medical records over on KevinMD.  The link is HERE.  Did you know that hospitals now send your medical information to the state (at least in our state), whether you want that or not? 

And while you're reading about privacy, there's a terrific article in the Wall Street Journal called Families of Violent Patients: We're Locked out of Care.

Okay, I'm going to make a confession here.  I have no idea what HIPAA is.  I don't know, I don't care.  My practice is small enough that I don't have to give out privacy notices, and I confine my "HIPAA" comments to "I don't release information without your permission."  I also note that I do release information in case of an emergency and that the state has requirements about the reporting of child abuse.  But from my take on it, HIPAA is not about who doesn't get your information, it's a long list of who DOES get your information, like it or not.  When I go to the doctor, I often cross out some of the listed entities, and tell them I don't want my information released.  But no one reads these things so it's just about making me feel like I have some control.  We all like those delusions.

Before HIPAA, doctors were not allowed to release your medical information without your permission.   There was this guy, way back when, named Hippocrates who had something to say on the matter.  Psychiatrists never did talk about your care without your permission, I remember this from before HIPAA.  

Regarding the Wall Street Journal article -- the implication here is that suddenly HIPAA prevents families from getting information about patients against their will.  I sometimes wonder if there is a reason the hospital/doctor/etc aren't plugging harder to talk with the family.  In the case of a violent patient, no doctor wants to see their patient hurt someone or die, and it's hard to imagine that if it were crucial to to share this information, a psychiatrist wouldn't say, "Listen, I can't treat you if you won't let me include your family."  The slant of the article assumes that the patient is always the sick one and that the family is well and harboring nothing but good intentions.  Perhaps the family has been intrusive, or the patient is really adamant.  Do we really want to tell a psychiatrist our private thoughts knowing they will repeat them to our family members whom we don't want to know them?  There are times when a really psychotic person won't allow communication because in the past, the family has insisted he take medication or go to treatment he didn't like, but which helped him anyway, and perhaps that was the right course of action.  But there are also times when families make the situation worse.  I don't think the issue is HIPAA, but I do imagine that part of it is that hospital staff don't have the time to work with patients and their families to help everyone come to a place where families know how to be helpful without being intrusive, and patients can feel more comfortable and respected.  These things take time (sometimes a lot of time) and if you're fighting with insurance companies for an extra day, and spending your time entering data into the computer, when a patient says "No, don't talk to my family,"  the doctor may just say "HIPAA, I can't," without exploring whether that makes sense or if there is a way the patient might allow communication about some aspects of care.  And finally, there is nothing about HIPAA that prevents family members from giving crucial information to a doctor.    

Okay, I've ranted for today.

Yes, You're Better

One of the fun things about Shrink Rap is that periodically ClinkShrink and I like to wrap our hands around each others' necks and squeeze really hard while screaming.  

So let me refer you to ClinkShrink's post below,  Am I Recovered Yet.  Read that first and come back.  It's a rich post with many different agendas. Don't worry,  we are on opposites sides of town and we are both getting sufficient airflow. 

1.  Clink talks about Tonier Cain who was horribly abused as a child, both physically and sexually.  Ms. Cain's abuse led her to a dysfunctional life of drug abuse, prostitution, and repeated incarcerations.  By dealing (whatever that means) with her trauma, she has overcome these problems, she now lectures on the importance of dealing with trauma, and she is a productive member of society.  I know nothing about Ms. Cain, this is what I gleaned from ClinkShrink's post.

2. Because of Ms. Cain's efforts, laws have been passed requiring that anyone working in a state facility must be trained in trauma-informed care, which ClinkShrink tells us has not been proven to be effective in studies. Remember, Ms. Cain is an individual who benefited, and studies look at populations, not individuals.

----Dinah's commentary:  I am going to stay out of the evidence-based medicine question because, well, evidence-based studies are limiting, they don't look at the full range of what we do clinically, studies are often conflicting, and sadly, we've seen that pharmaceutical companies have skewed some studies.  
      Moving on, I am against the concept of legislating medical care and medical standards.  I agree with Clink (take a breath now) that there should not be laws requiring training in trauma-informed care.  There should be industry standards and mandates; lawmakers shouldn't be requiring CPR training.  The law doesn't require me to have a flu shot.  My hospital, however, has said that if I'd like to continue treating patients there, I need a flu shot (I had a flu shot).  There was a really nice article on the intrusion of legislation into the practice of medicine a few weeks ago in The New England Journal of Medicine, see  "Legislative Interference With the Physician-Patient Relationship."

3.  Clink goes on to question whether Ms. Cain is really better if she continues to be fixated on issues related to her trauma.  Wow.  Let's see, she was a  homeless, drug abusing, criminal who sucked resources from society (I'm assuming that the tax payer funded her forays into prison) who now living in free society, working to help others, on a mission (I love people who have missions), and doing well for herself.  Yup, she's better.  Is she cured?  I don't know.  I don't even care. I'm with the commenter who suggested that the patient is the one who determines better.  She's feeling good about herself, presumably making a living (there's an award winning movie), lobbying for something she believes in, looks like she's raising her kids, getting a message across.  She's not homeless, not smoking crack, not in jail.  Does she need to be an accountant to be 'better?"  Plenty of people get better by focusing on their past problems.  Is the incarcerated drug addict who later becomes an employed addictions counselor who helps others not 'better' because he still lives his days thinking about addiction-related issues?  Yes, they are better.  Is it any different from the person who goes on to be an oncologist because his mother died or cancer, or the person who becomes a psychiatrist because he had personal or family experience with psychiatric problems?  What about my short friend who became a pediatric endocrinologist?

4.  Is she Cured?  Clink defines this as being symptom-free, able to move on to a life not involving a focus on their problems,who no longer requires resources and frees up these scarce resources so that others can use them.  What a funny way to define "cure" in a field where 'serious mental illnesses' are often chronic or recurrent.  I'll go with Freud here: "Well" is about the ability to work and to love.  It's not about the ability to live life free of symptoms. Is she Cured?  What does is matter?  Why does that need to be judged?

5.  Clink tells us that her goal is to get someone to zero symptoms (--I would never qualify, I didn't sleep well last night as I was worried about the election) and free them of being her patient.  "Government money for mental health services is limited, and should be directed toward people with serious mental illnesses and evidence based practices."

I'm not sure what ClinkShrink is getting at here.  I agree that government money should not be used for mandating training in trauma-informed care.  We don't mandate training in schizophrenia (it comes as part of psychiatry residency training and it's mandated by those who oversee residency training programs, not legislators).  I'm not sure what she means by 'government money' or by 'serious mental illnesses.'  So a patient with Medicare should not be allowed to access mental health services for a mild mental illness?  What's mild? Anxiety?  Election-angst?  Irritability with co-workers?  What if a person finds that a medication or a regular psychotherapy appointment helps their personal comfort level, and that by maximizing their comfort, they are better able to function as a parent and thus help a future generation?  What if having somewhere to process their issues makes it easier for them to function as a surgeon, or as a teacher. Okay, you say, not government funds.  But then what if our surgeon who feels better with care, or our legislator who influences the lives of thousands, or our public health researcher who benefits from care, what if they turn 65 and are now having services paid for by Medicare, do we bounce them off?   We don't tell people they can't have repeated doctor's appointments for belly pain, why should we limit care to those with "serious mental illness" whatever that is.  

Okay, I'm ranting. Clink, let go of my neck now. 

How Would You Fix the World?

Ah, our candidates have been debating, and everyone has a fix for society's woes.  Romney has an easy plan: cut taxes, this will let businesses keep their money so they can hire more employees, create more jobs (he has the precise number, even) and help the economy grow and everything will fall into place.  If we cut funds to Medicaid, Medicare, undo ObamaCare, and fire Big Bird, then we'll be able to pay off the trillions of dollars of National Debt, all while growing the military, and all will be well.  I know, I'm exaggerating, and it really isn't clear that cutting government funds to public television would mean the demise of Ernie & Bert.  Obama -- I'm not sure what his plan is to save the nation, but whatever it is (? more of the same), it's probably not going to lower the national debt.  It seems we live in a place where our expenses exceed our income.

I don't want to use this as a soapbox to express my political views or to influence your vote, instead I want to tell you that sometimes I have fantasies about how I would fix the world.  Actually, I have a lot of them.  I thought I would tell you my main thought, and ask you to tell me yours.  I'm a doctor, I've never taken a single econ or poly sci course in my life, so please be gentle with me.  It's just a fantasy.  And I won't make fun of yours.

So here's my thought, and unfortunately, it would entail more spending by the government.  I would like to see public schools mandated to have class size limits, preferably to 10-12 students, for certain grades, in any area where poverty levels are high, crime and drug use is a problem, and graduation rates are low .  I'd like to see the class size brought down for either first or second grade so that each student could get intensive, individualized education so that as many children as possible would get a good start with being able to read, because once they fall behind here, they're lost forever.  I'd like to see school days be longer and include some time on the weekend. It doesn't need to be all grind and work: wouldn't it be great to include an hour a day of sports and exercise for children in poverty regions where obesity rates are highest?  And games (Scrabble, anyone?), music, and ideally a bit of immersion in a second language?  It would be very expensive: more teachers (oh, and more jobs for teachers...), more classrooms (oh, and more construction jobs to build the classrooms), more resources all around.  And longer days would give children a chance to do their homework in school, provide child care so that their parents could work and have more disposable income, and keep the children out of drug-ridden, dysfunctional environments.  (I'd be fine with having the extended day segment be optional).  Oh, and Head Start has tried such things and the children make gains, but they only last for 3 years.  Okay, so look at the school curriculum and figure which years are the most crucial in maintaining a student's success, and shrink the class size for a few other years.  Maybe we make sure everyone is able to read and do basic arithmetic by the end of 2nd grade, and make sure everyone can write book reports and simple research papers, manage money and measurements, know a little about science,  how to read a newspaper, keyboard, use technology,  and start to think critically in 5th grade.   Too expensive, you say?  And I would counter with Really?  It would entail putting much more money into education, and making sure it goes to direct child-centered resources, like teachers and books, and not towards more administrators, or more standardized tests.

  So how does this fix the world?  Well, perhaps if we can impact these children early, they will be in a better position to succeed later, they will have feel more self-confident and won't view selling drugs as the only way out of poverty.  They will be more employable, and more likely to contribute, rather than drain, resources.  And perhaps if just a few less children from every class end up in jail, that could pay for my plan.  We hear outcries about public spending, and certainly, in wealthier areas where children do fine in classes of 30, there would be an outcry that their children should have smaller classes, especially since they are paying more taxes, but those same people don't object to spending $25-50,000 a year of their taxpayer's money to house those same children in jail when they grow up to be criminals.  

Thanks for indulging my fantasy.  I would love to hear your plan for fixing some of our problems. 

Preventing Violence: Any thoughts?

In the news today, it was noted that the alleged psychiatrist of the alleged Aurora shooter had allegedly been concerned about him enough to report him to the University's "threat assessment team."  He reportedly withdrew from the university before the team could convene.  We don't know any details about what he may have said to the psychiatrist, or what the threshold is for notifying their threat assessment team.  Presumably (and I don't know this for sure, but I'll assume) he would have been hospitalized if there was an imminent risk of danger.


Our laws are pretty clear, and I will only talk about Maryland, because I know nothing about the laws in other states.  If a patient makes a threat to a psychiatrist and there is a specific named victim, the psychiatrist is obligated to do one of three things: warn the victim, tell the police, or hospitalize the patient.  "I'm going to kill my girlfriend" qualifies.  "I feel like hurting people when they're rude to me" does not.  But wait, if a psychiatrist has reason to believe that a patient is at risk of committing an imminent act that endangers himself or others, and the patient has a mental disorder, the psychiatrist may involuntarily certify him to a hospital for psychiatric evaluation and treatment.  In the majority of cases, this occurs in the setting of a suicidal threat or after a suicide attempt.  It's much rarer that we see homicidal people in psychiatric settings, perhaps because depressed people become suicidal and seek care, while homicide more often is the result of anger or other motives (for example, in the course of a robbery) and not related to mental illness.  Mass murders in public settings are extremely rare events -- as opposed to suicide which is a common event, or single murders linked to drugs or alcohol which are also fairly common, at least where we live.  We know very little about what motivates mass murderers, and because they are so rare, they do not represent a single phenomena -- each case may have a very different motive and/or relationship to mental illness.


When something bad happens, and there were warning signs, people say "something should have been done."  If a psychiatrist has been involved, there certainly may be the thought that the psychiatrist should have prevented this.  The shooter involved in the Virginia Tech shooting had been hospitalized, years before the Va Tech incident, but he did not continue in treatment.  In many states, patients whose mental illness leads them to legal difficulties are subject to outpatient commitment.

We don't know what transpired in Aurora, but if a student in Maryland made a vague threat (and vague threats do keep psychiatrists awake at night) and then left the institution, or simply didn't return to treatment, there is little that can be done.  If I'm worried about someone's safety, I like to check in with the family: Are they worried?  Are they aware that the patient owns weapons -- if that's what I've been told.  I like them to at least be aware that I'm concerned, to know how to find me, and to know what to do if there is a emergency.  If there's no family, or if I don't know how to reach them, then this isn't an option.  

Our present laws don't allow us to involuntarily hospitalize people based on vague threats, or shrinky suspicions, and they shouldn't: we don't want to be a society that institutionalizes everyone who seems a little weird or is a loner. ( I don't even think we want a society where everyone has to have their shoes scanned to get on a plane, but nobody asked me. ) We're not terribly good at predicting violence -- people get discharged who then commit violent acts, and people get committed who would not have acted on their violent thoughts.  We're psychiatrists, not fortune tellers.

Are tragic acts of violence a failure of the system, or are they an unpredictable, fact of life where any attempt to prevent such acts would result in an over-correction and too many people would end up having their civil rights violated?    Is there some other possible solution -- something more or different that could be done without risking the civil liberties of those who will never harm anyone? Should we be completely re-thinking this, outside the box of hospitalization/compelled care/ and commitment?  Any ideas?
Oh, wait -- before you use this as your gun-control soap box -- the alleged Aurora shooter is not the right poster child, even without guns, his apartment full of explosives could have resulted in a horrible tragedy without guns.  (I'm in favor of tighter gun regulation, and I don't believe it's okay to buy or sell thousands of rounds of ammunition over the internet, but that's a different issue.)


Okay, Clink can tell me why I shouldn't have written this blog post now.   And Roy, for you, I've started balancing my dashes -- I know how difficult it is for you when I don't.  Thanks to Tigermom for the graphic

Blame the DSM?

In the Washington Post, April 27, 2012, "Psychiatry's Bible, the DSM, is doing more Harm than Good," Paula J. Caplan writes:


About a year ago, a young mother called me, extremely distressed. She had become seriously sleep-deprived while working full-time and caring for her dying grandmother every night. When a crisis at her son’s day-care center forced her to scramble to find a new child-care arrangement, her heart started racing, prompting her to go to the emergency room.

After a quick assessment, the intake doctor declared that she had bipolar disorder, committed her to a psychiatric ward and started her on dangerous psychiatric medication. From my conversations with this woman, I’d say she was responding to severe exhaustion and alarm, not suffering from mental illness.

Caplan goes on to express her concerns with psychiatric diagnoses, the DSM, the problems with these labels that lead to the use of dangerous medications.  Oh, we've been here on Shrink Rap before, see "Diagnostic Labels That Change Lives". 

Caplan continues

In our increasingly psychiatrized world, the first course is often to classify anything but routine happiness as a mental disorder, assume it is based on a broken brain or a chemical imbalance, and prescribe drugs or hospitalization; even electroshock is still performed.


According to the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defines the criteria for doling out psychiatric labels, a patient can fall into a bipolar category after having just one “manic” episode lasting a week or less. Given what this patient was dealing with, it is not surprising that she was talking quickly, had racing thoughts, was easily distracted and was intensely focused on certain goals (i.e. caring for her family) — thus meeting the requisite four of the eight criteria for a bipolar diagnosis.
When a social worker in the psychiatric ward advised the patient to go on permanent disability, concluding that her bipolar disorder would make it too hard to work, the patient did as the expert suggested. She also took a neuroleptic drug, Seroquel, that the doctor said would fix her mental illness.

Caplan goes on to say that because of the existence of a psychiatric label-- one she contends is wrong-- the patient lost her friends, her marriage, her home, her self-confidence, her wealth, was forced to move across the country to somewhere she was isolated, and the six weeks she spent on medication (presumably Seroquel) left her with a condition that may someday leave her blind. 

Mental health professionals should use, and patients should insist on, what does work: not snap-judgment diagnoses, but instead listening to patients respectfully to understand their suffering — and help them find more natural ways of healing. Exercise, good nutrition, meditation and human connection are often more effective — and less risky — than drugs or electroshock.


Caplan, a Harvard psychologist, goes on to discuss a complaint she is helping to file against the DSM editors on behalf of 10 patients who were misdiagnosed. "Psychiatric diagnoses," she concludes, "are not scientific and they put people at risk."
-------------

Where do I even begin?  Please, please, I don't know the patient, I only know the presentation given, and I'm going to be very sarcastic, because the way it was presented struck me a ridiculous and it distracted from some valid points that might have been made if there wasn't the Evil, Idiot Psychiatrist Theme with a sensationalist tone.  Shame on the Washington Post for printing this.

Okay, so   I couldn't quite follow the case she presented, at first it sounds like the patient went to the ER with symptoms of a cardiac problem, or exhaustion, or a maybe a panic attack.  Perhaps, but some imbecile ER doc did a check list of symptoms, told her she had Bipolar disorder, and without even listening to her,  weighing other options, or taking into consideration the context of her life,  sent her off with Seroquel and a recommendation for  therapy.  This misdiagnosis then destroyed  her life, because  why would her husband and friends stick with her if she's got bipolar disorder?  What better time to leave your wife then when her grandmother is dying, she's stressed out and sick?  So she went to the ER because she was tired and her heart was racing.  I think they see this all the time...I think they do an EKG and perhaps make sure the patient isn't having a heart attack or arrhythmia, and if they think it's anxiety, the patient gets a dose of a benzodiazepine, and gets sent home.  Okay, but it's an ER and the docs are rushed and focused on what the patient needs now.  They make wrong diagnoses all the time, and it's not just psychiatry, and it's not just  because the doctor is sitting there with the DSM or has memorized the hundreds of possible diagnostic criteria.


Okay, but it turns out that she was on a psychiatric ward.  You can't get admitted to a psychiatric ward because you're tired, with racing thoughts, a fast heartbeat, talking fast and being distracted.  Pretty much, you need to be a danger--, suicidal, or having severe hallucinations or delusions, or be in extreme distress in some way.  This was a wealthy patient who could afford outpatient care.  All I'm sure of, is there is something more to the story. 


Finally, the patient was admitted to a psychiatry unit, so presumably there was a second doctor who met with the patient and a treatment team that observed her behavior for a few days.  Okay, I've stories of really lousy inpatient care, and I do believe the diagnosis could still be wrong and the treatment that was recommended might be wrong, or helpful at the moment but not necessary for the long-term, but I don't buy that a misdiagnosis let to the complete demise of this patient's life and a need to move across the country.  These are the types of problems one sees as a result of the behaviors a person might have because they have a mental illness, perhaps one such as bipolar disorder.


So I don't know the patient, or the diagnosis.  But I do know that the entire premise for this article is based on the idea that the patient was simply tired and stressed and perfectly normal and did not have a psychiatric disorder (the author tells us this) and this label alone destroyed her life.  The reader is not allowed to even entertain the idea that the patient had a psychiatric disorder-- that maybe the psychiatrist did get some history and make reasonable observations, and the patient really did have bipolar disorder? (Obviously, I don't know this).  There's no mention of a review of the records, discussion with family, interview of the doctor, Caplan is telling us her impression based on the patient's report only.   Maybe the patient had panic disorder, or a personality disorder, or even an adjustment disorder (perfectly possible given the stresses involved).  Oh, but then she took a bum recommendation to go on disability, and she got it!  I've seen really sick people not get disability.  It takes a lot of documentation and the government looks for ways to avoid paying this-- you don't get disability for having a psychiatric diagnosis, you have to be disabled by it.  So, somehow, this patient who  was simply exhausted and stressed, with No Psychiatric Disorder, per Dr. Caplan, managed to get admitted to a hospital and get disability benefits.


There were some valid points Caplan could have made.  The DSM is not a 'scientific manual.'  Personally, I don't find it terribly helpful in clinical practice.  I don't keep a copy in my office (I bought one to use while writing Shrink Rap), and I'm not planning to buy the DSM-V.  The overall concept is good, and it's very helpful to researchers to be certain that the groups they study have some diagnostic reliability, otherwise there is no way if knowing if a certain treatment addresses a specific group of people who can reliably be classified as having a specific illness.  This isn't all bad, but I don't need 370-400 diagnosis for my work (predicted in the new DSM-V).  And Caplan makes the statement that the editor, Allen Frances, says the work is based in science but has spread it's net too far.  If you read Dr. Frances' blog, you'll note that he is quite skeptical and opposed to many of the proposed changes for DSM-V.   It's not like the psychiatrists aren't thinking hard about these diagnostic categories and the ramifications they have.  Still, I'm skeptical about how we think about these disorders, especially Bipolar Disorder. 


I agree with Caplan that psychiatrists should listen more.  Fifteen-minute med checks have made a mockery of our profession.  I also tell all of my patients to exercise, eat healthy, and look for ways to solve their problems.  But to imply that these things are the answers for the majority of people who are suffering (and often too distressed, depressed, and unmotivated, to just pull up their bootstraps,  get up and exercise and cook a healthy meal )-- is an insult.  You know, sometimes those things really do work, but if people are able to do those things, they've often tried them before seeking psychiatric opinions.  To read Caplan's piece, you'd think everyone is an idiot.  And finally, ECT: it still in use because some people find it helps.


Okay, I am ranted out.  

Should State Legislators Determine Indications for Medical Treatment?

The FDA evaluates studies on medications and deems them safe enough to justify use.  They also determine the "indications" for using any particular medicine, and once that's done, physicians will often use a medication 'off label.'  That means that Medicine A was found to be safe (or relatively safe, because even over-the-counter meds can be fatal for the wrong person at the wrong time), and it works better than a placebo at treating Disease A, but some studies have found it useful for Disease B, but the FDA hasn't gotten to approving it for this yet, and perhaps never will, but docs use it for Disease B anyway.  This is very common with the SSRI's, where one has been approved for a condition, but maybe the patient isn't tolerating that one so well, so the doc uses another SSRI with a different side effect profile, even though that particular med has not been approved for that particular condition.  Just an FYI, the SSRI's are : Prozac Zoloft Paxil Luvox Celexa Lexapro.   


So the FDA says inhaled marijuana (as opposed to Marinol, a pill form of cannabis) has no medical uses and the discussion is ended.  It can't really be studied at this point, because it has no medical value so your local university can't grow or get any weed and do studies on it, because it has no medical value.  And the federal government says it's illegal.   I do believe that with 16 states disagreeing, that perhaps the FDA should reconsider this stance and repeat a study or two on inhaled cannabis for nausea induced by chemotherapy or anorexia in AIDS so that medical marijuana can be studied, monitored, grown in a pure regulated way, prescribed for a known and proven condition with some parameters like other medical interventions: 30 day supply, directions on how much and how often to smoke it (ah, the pharmacy could roll for you), reassessment so that if your doc decides to give it to you "off label" for your low back pain, and that pain is so much better but funny, you've stopped working, you lie on the couch all day playing Grand Theft Auto, and your life has virtually stopped, the doc can say, "Glad it's helped your pain, but it's put you into an apathetic, amotivational state and your life has now gone down the toilet, I'm stopping this so you can go back to work and pay the mortgage and feed those hungry children."  Or for us shrinks, "Funny, but you didn't have schizophrenia until you started smoking this stuff, let's stop it."  Obviously, if the person has become addicted (and yes, you can get addicted to weed), they'll get it illegally, but the same is true of benzos or opiates, and really medical marijuana just can't be any worse then the fiasco we've had in this country with oxycontin, especially when it gets mixed with a bit of also-legal Xanax and also-legal Vodka, and I can give you a long list of names of people who can no longer testify to this, famous and otherwise.  


So for the moment, the demand for legalized Medical Marijuana is left in the hands of our legislators.  Who better to determine medical indication, necessity, length of treatment, and methods of monitoring.  In Maryland, there was a study group led by the state's health secretary, Joshua Sharfstein.  The plan called for going slow, required training of docs to prescribe it, and required that it be distributed through academic centers.  Two legislators who are pushing bills to legalize medical marijuana called it Misguided and Heartless.


Delegate Glenn of Maryland has proposed House Bill 15, a Medical Marijuana Act.  It provides that marijuana could be used for a variety of conditions.  They include: 

(1) “DEBILITATING MEDICAL CONDITION” MEANS:
(I) A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION OR ITS TREATMENT THAT PRODUCES ONE OR MORE OF THE FOLLOWING:

1. CACHEXIA OR WASTING SYNDROME;
   
2. SEVERE, DEBILITATING, OR CHRONIC PAIN;
   
3. SEVERE NAUSEA;
   

4. SEIZURES, INCLUDING THOSE CHARACTERISTIC
OF EPILEPSY;
5. SEVERE AND PERSISTENT MUSCLE SPASMS, INCLUDING THOSE CHARACTERISTIC OF MULTIPLE SCLEROSIS OR CROHN’S
DISEASE;

6. AGITATION OF ALZHEIMER’S DISEASE;
   
7. ANXIETY; OR
   
8. DEPRESSION; OR
   

(2)
VIRUS (HIV);

“DEBILITATING MEDICAL CONDITION” INCLUDES:

1. (I)  CANCER;
   
2. (II)  GLAUCOMA;
   
3. (III)  POSITIVE STATUS FOR HUMAN IMMUNODEFICIENCY
   
4. (IV)  ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS);
   
5. (V)  HEPATITIS C;
   
6. (VI)  AMYOTROPHIC LATERAL SCLEROSIS;
   
7. (VII)  NAIL PATELLA;
   
8. (VIII)  POST–TRAUMATIC STRESS DISORDER;
   
9. (IX)  BIPOLAR DISORDER; OR
   
10. (X)  THE TREATMENT OF ANY OF THE ABOVE LISTED CONDITIONS. 
    
    
    On the positive side, the law does require that "compassion centers" to either grow or distribute marijuana be at least 500 feet from pre-existing schools.  Because children can't walk 600 feet?  
    
    I'm told this bill won't pass, but another one, with out the listed psychiatric indications for the use of medical marijuana, may well pass.  I might be more pro-MMJ if the stats didn't reveal that 2% of recipients in Colorado have cancer and AIDS, and that many people are prescribed marijuana by non-psychiatrists for psychiatric reasons, including insomnia.  And if medical marijuana was distributed by a pharmacy with directions on how much and how often to use it.  The one-year toke your heart out cards with the boutique flavors all as part of "wellness" don't fly so well with me.  If people want marijuana to be legal, then legalize it, but this type of legislation puts physicians in the middle as an agent.  Really, if we were talking about people smoking a little during their cancer treatments, this just wouldn't be the issue that it is.
    
    Okay, so my questions for you:
    
    1) A person gets medical marijuana for back pain or anxiety or whatever.  He gets arrested.  Should it be continued in jail?  Prison not be such a bad experience if you get to be high the whole time?
    
    2) Shrink Rap readers don't really like uninformed consent with meds.  How do we feel about giving it to agitated Alzheimers patients and how would that work?  Can you smoke in nursing homes?  Do they have to taken outside in restraints?  Agitation is not usually associated with early Alzheimers.
    
    3) Do we think it's just a little weird that a state legislator is making laws listing which medical indications a drug should be used for?  I must have missed those lectures in residency where pot is the treatment for depression, etc.   Can legislators also decide that methotrexate should be legal for the flu?  I sort of don't get it.  
    
    Okay, my rant for the day.
    

Empathy and Air Travel

A few days ago, I ranted about how I was detained by security at an airport, then lost my computer.  I've put an update on the bottom of the that post: My Disasters, Natural and Otherwise.

So let me talk about my new friend, whom I've never met and whom I know pretty much nothing about, Steve Silberman, blogger over on Neurotribes.  Now I've never actually read much of Neurotribes, and maybe he express opinions that would make me feel ill, but when one of our readers pointed out the post called "Dear United Airlines: I Want My Kindle and My Dignity Back", I felt like I had found a soul mate in my distress over my lost laptop and the frustration I have felt in trying to inspire some sense of caring or empathy from TSA or the airlines. 

Mr. Silberman writes:

The metaphor of frogs that don’t notice the water around them is getting warmer until it’s boiling (and they’re cooked) is only an urban legend, say the vigilant debunkers at Snopes.com — but it’s an apt image for today’s frequent flyers. Schlepping their carry-ons through security mazes, standing shoeless with arms outstretched in bleeping machines, shrugging off dramatic confiscations of shampoo and toothpaste, and frantically rejiggering carefully-plotted itineraries at a moment’s notice, we’ve come to accept the current state of affairs as just another way that life sucks in the post-9/11 era. Never mind that I’m old enough to recall when a cross-country trip on an airplane, even in economy class, offered an opportunity to unwind and feel coddled in the lap of luxury for a few hours with a stratospheric view. Now I look forward to flying about as much as I look forward to a trip to the dentist.


Okay, Steve, it was nice to meet you. 

My Disasters, Natural and Otherwise, now updated.



Roy is Driving Me Crazy!

I'm at my office today and I turn on my phone between patients. There's a text and a message, both from the same person. "Where is Roy, he's supposed to be here at a meeting? Can you contact him?"

Interesting. I scratch some body part or the other. Am I Roy's mother? Did someone forget to tell me? I forward the text to Roy, and welcome in the next patient. After that session, I check messages again. Roy has texted me, "I can't talk, I'm in a meeting." I guess he got there. Oh good.

And the blog. We have a rule about the sidebar: Dinah doesn't touch it. It's Roy's rule, but I've had a few problems, so mostly it's okay. But then, I decided I wanted a duck on the side bar. I put one up. That I can do. Roy took it down, because if I say Earth, Roy says Mars. Duck> No duck. No duck> Duck. Should I start reverting to reverse psychology? What was wrong with the duck? I liked it. Roy put up a link to our book's Facebook page---you remember, that book we've been writing for about a zillion decades that never actually materializes. I promise (I hope) that it isn't just a pipe dream. So the book's Facebook page has a whopping 8 fans and their photos are shown on our sidebar. Does Jesse the Chinchilla Lover want his photo on Shrink Rap? Do we want to advertise our 8 fans? I take it down. And Roy tells me he's frustrated that I undo things he does without talking to him first. But my duck-- he took down my duck! And he didn't talk to me first.

Why does Roy want the Facebook page up anyway? Does it matter? How will our Shrink Rap Book FB page change the world? Oh, we had tried a Shrink Rap friend page, but that was too hard to manage. I had to sign out of my own account and confirm new friends, and interact with them, and I'm a bit on overload (in case you couldn't tell!). We tried a "fan" page and that was fine. Only it was linked and combined with the friend page and who knew what was what. I was pretty confused and I created them! So Roy made us a FB book page, only the book's not out, so he doesn't want anyone to know. But he does want 25 people to be fans so he can reserve a specific URL for it. HuH? And then he put his twitter feed in to it which would be good---Shrink Rap posts would populate the wall, but then he had a twitter conference and all sorts of random tweets went twitting away on the wall and in my News Feed. I think I'm way too old for this. Anyway, Roy is driving me crazy.

Please join our Shrink Rap Book page so Roy can drive you crazy, too.

And Clink has a new "old" post up on Shrink Rap Today over at Psychology Today.

Just One More Question....

Thanks to Peter for bringing this article to my attention.

Have I ever mentioned that I hate forms? Oh, it's not just Medicare forms, it's all medical forms.
In private practice, there's not much paperwork. I see patients and I jot down a note for their charts. Sometimes I type a formal evaluation for their primary care doctor. Sometimes I need to fill out treatment plans or preauthorization forms for medications or forms for disability insurances. And these things are a pain in the neck, but most days there are no forms. I see patients, I turn off the phone, and I'm with them fully.

In the clinics where I've worked, the notes go on forms. There are simple questions to be filled out, nothing that exciting, but it pulls my attention. There's a line for the date. Oh, I do that anyway. Diagnosis. Usually I know that. Time I started. Oh, who cares? Usually I'm talking with the patient and realize I forgot that. I turn to look at the clock and record the time. First zap away from the patient. Age: ? I look at their birthdate. I subtract from the current date to get the year. Why do I have to calculate the age of every patient I see everytime I see them? There are computer labels on every page with the date of birth. If someone wants to know, why can't they do the math? Medical Diagnoses and Medications: I look that up. Date of last physical: ? I look that up or ask the patient. If it's been a while, I tell them to have a check up: Maybe that's useful, but every patient, every visit? I check the box that says they aren't suicidal and that I've discussed the risks and benefits of the medications and how often they come for therapy and what the goals are and if they are getting labs done. I update the medications on the log sheet and in the electronic record. I send a letter to their primary care doc listing their current psych meds: this is required even if their current doc is at the same hospital and can access the updated medications on the EPR. Time ended? I glance at the clock and record it. Duration of appointment: ....Oy, someone else can't subtract the minutes? I've taken to writing 17.3 minutes. Oh, and in there, there was lots of time to hear about the patient's life.

Okay, I'm ranting, but I felt vindicated when Peter sent us all Teresa Brown, R.N.'s article in the NYTimes Well Blog, "Caring for the Chart or for the Patient." Nurse Brown writes:

Because that’s my real concern: the effect on patients of incessant record-keeping. Each of these individual initiatives has merit and is worthwhile, but together they become a mishmash of confusing and oppressive paperwork.

She's Coming Undone

I like to understand the things I own, to use them to their fullest, to know my options and pick and choose from an educated stance. I'm kind of all-or-nothing that way, and well, life in this technologic age has kind of undone me. I stopped watching television years ago. I remember in the days of old back when we walked barefoot through the snow the eleven miles each way to school when you turned on a television by walking up to it and turning a dial to go from Channel 2 to 5 to 7 to 11 to 13 and that was it. Now it takes 4 remotes to get my TV on (?maybe it's only 3-- there's the TV, the sound, the satellite) and I get 800 channels and can't figure out my choices and by the time I surf the landscape, and figure out what I want to watch (do I watch TV or TiVo?) and what I might like TiVo'd for later, well, it's time to crawl into the coffin.

Clink and Roy love it. They can spend hours comparing their IApps and who's bubblewrap is loudest and the joy that can be found from the Koi Pond application is just amazing. I have an iTouch-- it has on it:
500 some odd songs that I listen to at the gym. A handful of music videos and I'd like more but the iTunes store makes me very dizzy and nauseus. One TV show (an episode of scrubs) and a bunch of Apps, of which I use about 3: the NYTimes, iLose, doodlebuddy, flashlight (which I never use) and a game called Firestarter which I'm addicted to. I just added Pandora in the hopes of more music at the gym. We'll see. I'd like more TV shows, but how to choose? I was watching Wine Spectator video podcasts for a while, but I lost interest in wine.

To make it worse, I have an email addiction, so I limit the places I'll get internet. Home--and it ruins my life. The clinic (it's here, I didn't ask), the gym (so I can read the NYTimes online), but not my office, and not as a portable because oh, a blackberry or iPhone would do me in.

So I'm out with Camel and she's talking about how she loves her Kindle. I never wanted one. Now I want one. Oh, or do I want that iPad thingy....maybe I could take it to the gym and play my music and watch TV shows that I can't seem to negotiate, or UTubes or Podcasts, or Apps or my head, I swear, it's going to explode into a million pieces. Maybe I don't want it, maybe I just think I want it, but Clink says I do want it. Will this end my life without data plans? 1450 daytime minutes and unlimited texting, a windows desktop, an Apple laptop, an iTouch, a palm pilot, podcast mixers and mics, how much more can one shrink take?

Hospital computer won't let me add a graphic. Just as well.

Is It Okay to Lie to Your Doctor?

It's snowy here in Maryland.

First, let me say that it's never okay to lie to your shrink. Therapy is about having an honest interaction, and a psychiatrist probably can't help someone who is hiding a secret life. This post, however, was inspired by Clink's last piece, Rage Against the Machine where she wails on Electronic Medical Records, in a feeble and failed attempt to engage Roy in a fist fight. There she is a punchin' and he's just skating along oblivious as can be.

Why do EMR's make me uneasy? When I'm in the clinic with patients and I can access their medical records, well, it makes life easier. So why don't I like the whole idea? I talked about some of this in the comment section on Clink's blog post.

With an EMR, it's easier to get records, and any doctor in an institution who treats a patient has access to them (oh, the whole institution has access to them, but only those involved in the patient's care are allowed to "peak"). What if a patient wants to withhold some of their information from certain docs? Is that lying? Is that reasonable? Should that be allowed?
If it's about obtaining prescriptions for controlled substances, it's just wrong. But might there be other reasons a patient would want to control the flow of information?

Let's face it, some docs and some patients don't click. A patient may feel the doctor didn't really listen, saw him much too briefly and jumped to a conclusion without hearing all the information, or was uneasy with the doctor's conclusion. The patient comes for treatment of his headaches, and after a few minutes, the doctor says it's "Stress." The patient wants more tests done, the doc feels it's unnecessary, and the patient would like to get a fresh opinion. Electronic Records may hamper the ability to get a fresh opinion. The next doctor may look at the note and agree with the patient that more testing should be done, or he may see another doc's opinion and go with that. And who knows what the first doc wrote, it may continue to prejudice future care. All sorts of human emotions get tossed in here: What if second doc hates/adores first doc, that may prejudice what side he takes. Any way you dice it, if the question is so much as raised that a patient is malingering or that an illness is factious, medical professionals may shut down.

So how does this pertain to psychiatry? Psychiatric patients are often given sub-par medical care. Their medical symptoms are more likely to be attributed to their psychiatric disorders (and sometimes this is appropriate after a reasonable and thorough work up). Perhaps a patient worries that if he tells a doc he's in therapy, his problems will not be considered as valid. I think this is getting better.

Roy would say that the patient should be involved in the evolution of the record. Maybe Roy should say what he wants to say....

And you didn't really think I was going to say if it's okay to lie to your doc!
-----------
So I'm adding this as a next-day addendum: Talesofacrazypsychmajor left us a comment saying that primary care doc who knew of psych diagnosis felt it had to go on every school form that needed to be filled out (presumably for school, work, camp) and perhaps that's a valid thing to reveal to any institution needing medical information. However, it is an example of how the patient is out of control of their information. This example is obviously not an EPR issue alone, but EPR's make the spread of information easier for better or for worse.

38 Cents per Cancer Stick

When I was growing up, cigarettes were something people bought from vending machines. I've never been a smoker, but I want to say they cost about a dollar? I'm not so sure, and it's not something I pay much attention to. Today, I learned that a carton of cigarettes cost $75! $7.50 a pack, or 38 cents a cigarette. So someone who smokes 2 packs/day, pays about $450 a month.

The funny thing is, I didn't know this because people never complain to me about the cost of cigarettes. They complain about the cost of medicines (this sometimes includes patients with medicaid who have a $1 co-pay for their meds), the cost of health insurance, and the cost of medical treatment. At times, I've suggested that patients with heavy habits cut down by one pack a month (so less than a cigarette a day) to be able to afford their medicines and I've been met with groans.

Do I think cigarettes should cost this much? Yes. The health problems they cause and the cost they inflict on society is so huge, that I believe they should be heavily taxed-- and the monies should go to medical expenses incurred by smokers and research on how to better prevent addictions (my personal rant, added at no additional cost). But I think it speaks to power of their addiction that people are willing to put out this huge sum of money on cigarettes-- people who don't have it, people who really can't afford it, people who would go without necessary medical insurance or medical care, meals at nice restaurants, vacations, and many other things that $5,000 a year would buy.

So why is this a Shrink Rap post? Patients with severe and persistent mental illnesses have higher rates of smoking than the population as a whole, and they also die a lot younger, often from cardiovascular disease. Check out this post on Psych Central.

Response to the Comments on the Last Post

So I wrote about the 12 ways to drive ME crazy...and it got a few comments. I've nothing better to post about, so I thought I'd address those comments here. My co-bloggers seem to have gone dark with posting. I hope it's okay if I reference the random commenters.

One commenter wrote in an additional idea:
13. Spend the treatment session being totally non-compliant and then tell everyone how useless your therapist is.

Fortunately, if my patients are feeling I'm useless, they aren't telling me. Many are non-compliant, and that just goes with the turf of being a shrink. I've been at it too long to take it personally or to be driven crazy by it.

Return of Saturn (what a great blog name!) is worried about returning to care after a few no shows and a few years. Personally, I'm always flattered when people return to treatment. I'm sorry they are feeling badly, but I like that they feel comfortable enough coming back. And No Shows are a pretty common thing, they aren't something that gets held in long term shrink memory. They do generally get charged for, however.

For everyone who commented on Calling Between Sessions: it's only necessary if a shrink specifically asks to be called. No one is waiting on unrequested calls. If a shrink requests a check in, then ends up chasing the patient down repeatedly, well....it gets to be plain inconsiderate. Often, however, we work on the No News Is Good News theory and lost sleep is the exception, not the rule.

Mindful wants to know what personal intrusive questions I get and the worst of them isn't going on the blog. Try This for a post on Questions for the Doctor.

Anonymous wants to know why I like Seroquel better than Xanax and says it's more toxic. I like Seroquel better than Xanax because you can give someone a very low dose to take as an emergency medication (yes, off label, and yes I explain this) and it's not addictive and doesn't cause physical dependency, so they can take it or not take it, while Xanax gets you committed fairly fast. Given all we now know about the metabolic issues with Seroquel and the atypical antipsychotics, I'm a lot more hesitant about giving these medications and it's fairly rare that I use them off label. At this point, this is really an emergency measure for someone feeling pretty desperate or on the verge of hospitalization. And Xanax isn't much of an issue any more because so few shrinks prescribe it on a standing basis that it's been a very long time since a new patient has come to see me already on Xanax.

The same Anon is also concerned that I don't want patients to come off meds when they aren't having side effects, or don't realize that they are until they come off meds.
I have to say that I have very few contentious discussions with patients regarding medications. Most people are on medications because they feel better on them, and I'm more often saying it's time to at least consider coming off (many people don't want to risk a relapse and I respect that). I'm with Roy here, who commented that it's really about working with someone and the risk/benefit ratio. My Drive ME crazy list referred to the quite rare case where someone has repeatedly come off meds only to relapse and either the relapse has resulted in hospitalizations, violence, or the patient's misery being so tangible that it felt like my own (and months of very distressed phone calls). Many patients stop their meds: I tell them what I think they should do, what I think the risk of relapse is, and from there, it's not my decision. And I don't stop treating anyone who says they feel better without meds and is willing to risk the unknown. I don't know what to say about side effects: if someone says they aren't having them, I don't argue. And often it's hard to tell the difference between a symptom of illness and a side effect of meds. I do a lot of my thinking out loud and try to share my thought processes with my patients. It's the best I can do.

To Spotsy and Mind Mechanic: thanks for the support.

And to Roy: mostly you got the list of what you do that drives me crazy right. The podcast, however, was your baby, and so it doesn't bother me that you don't post them after we make them. I love your company for it's own sake, so I don't lose sleep over unposted podcasts. ClinkShrink, however, may feel differently. Please please please don' t post what I do that drives you crazy. I don't want to know.

How to Drive ME Crazy

The last post was stolen from another blog and was meant as a joke.
Here's my personal list, it's not a joke.

1. Don't show up for an appointment. Don't call. Don't answer your cell phone. Don't return my concerned calls.
2. Don't show up for an initial appointment where I've blocked out two hours for you. Don't answer your cell phone, never contact me again. Ignore the fact that I made a point of requesting a call if the appointment wasn't going to be kept.
3. Insist that Xanax is the only medication that works for you and refuse to try anything else, even once, even if you've never tried it before.
4. Insist that a 90 day supply of a very expensive medicine must be written because that's the only way you can afford it through the insurance, and two weeks later announce that it suddenly no longer works.
5. Present in a crisis, sit through a session where we develop a plan, then return having done none of it.
6. Decide that the medication that was the only thing that worked for you after years of trying to find something, anything, that would work suddenly is something you don't want to take, even though you've been on it, stable, and doing well for a few years with no side effects. When your psychiatrist reminds you how awful your last 7 episodes of illness were, how hard it was to get you better, and that statistically the chances are extremely high that you might get sick again and it might be hard to get you well again, say, "I'm not going to get sick again."
7. Attribute your flagrant mania to "real emotion" and insist your psychiatrist can't understand because they aren't Italian/Irish/whatever. (Oh, this doesn't really bother me.)
8. Spend the session discussing just how suicidal you're feeling and how badly things are going, and at the end of the session announce that you need to decrease the frequency of the sessions.
9. Promise to call between sessions when your shrink is very worried, then don't. Rest assured, shrink will remember you didn't call at 3 AM.
10. Ask your shrink very intrusive personal questions. I'll spare you the examples.
11. Cancel ten minutes before a session. Tell shrink you suddenly remembered a conflicting appointment that was scheduled a month ago.
12. Leave treatment without a word after years of therapy and leave shrink to wonder how you are and how all the details of your life turned out.

I could probably go on for a while. I liked some of the ones people put in the comment section of the last post.

Ringing In A New Year!

It's over. It's over. Can I tell you how glad I am it's over? Did anyone have a good year? Michael Phelps seems to have managed okay. And somehow I think Barack Obama enjoyed 2008 more than he will enjoy 2009.

The rest of it: it can be done with.

We saw the worst stock market decline in 77 years with the S&P 500 down about 40 percent. Banks failed, housing prices failed; who's next in line for a bailout? Lehman Brothers liquidated, Merrill Lynch sold out, the list goes on.
We're still fighting a war in Iraq, and Afghanistan. Terror in Mumbai, continued unrest in India and Pakistan, the war between Georgia and Russia, nuclear power in Iran, and Hamas and Israel continue to fire on Israel with no signs of peace.
An earthquake in China, floods in the midwest, I lost count of the hurricanes-- Ike and Gustav, to name a couple. Wildfires in California.
We've learned that a single man can steal tens of billions of dollars over the course of decades without being detected. And a governor can try to sell a senate seat. Trust-- what's that?
I've ignored whole continents here--

Time to move on.... Here's to hope for a better 2009. I'm ready.