Guest Blogger Dr. Meg Chisolm on Systematic Psychiatric Evaluation

Over on our Clinical Psychiatric News blog, I've written a review of a new book, just published by Johns Hopkins University Press, Systematic Psychiatric Evaluation,  A Step-by-Step Guide in Applying The Perspectives of Psychiatry, by Margaret S. Chisolm, M.D. and Constantine G. Lyketsos, M.D., M.H.S.  Do check out my review over on CPN (it should be up later today), along with ClinkShrink's article on "Debunking The Mad Artistic Genius Myth" and Roy's piece on World Mental Health Day which lists some great resources. 

Dr. Chisolm was kind enough to write a Shrink guest post for us on her inspiration for writing the book, with just a little about French cooking.  Sorry no recipes here.  Meg writes:

I did my psychiatry residency training at Johns Hopkins University in the late 1980s, under department chair Paul McHugh and residency director Phillip Slavney.  These leaders also are the authors of the textbook The Perspectives of Psychiatry, whose principles informed the way I and a generation of Hopkins psychiatrists since have been trained.  The basic idea of The Perspectives is that by conducting an evaluation that considers a patient’s psychiatric presentation from each of four perspectives, the clinician can better understand the nature(s) and origin(s) of the patient’s problems, and develop a more comprehensive and personalized formulation and treatment.  (The four perspectives are: disease, dimensional, behavior, and life-story.) 

The most frequent question raised about the Perspectives model by trainees and clinicians unfamiliar with the approach is “How are the Perspectives any different from Engel’s biopsychosocial model?”  In response, McHugh and Slavney are fond of saying that the biopsychosocial model provides the ingredients (atoms to biosphere) for understanding patients with psychiatric illness, but the Perspectives provides the recipe.  I like this analogy (or is it a metaphor?) because, in addition to enjoying my work as a psychiatrist, I like to cook.  But, more about that later. 

As a Hopkins-trained psychiatrist, I had probably read The Perspectives of Psychiatry about five times, beginning with my stint as a medical student during my sub-internship at Hopkins.  Let me tell you, The Perspectives is a good, but hard read.  As a student, I don’t think I understood much of it.  Reading it again as a psychiatry intern, having seen many more patients with psychiatric conditions, it started to make some sense.  As a junior resident, I began to understand it a little better, which was a good thing since – by then – I was expected to be teaching the book to medical students.  By the time I was a chief resident teaching junior psychiatry residents how to apply the Perspectives approach to patients, I thought I had it down.  Well, I was wrong.  It wasn’t until I began writing a casebook companion to The Perspectives of Psychiatry that I finally figured it out.  So, if the biopsychosocial method provides the ingredients and The Perspectives of Psychiatry the recipe, that’s one highfalutin’ cookbook!  And that’s where our new book Systematic Psychiatric Evaluation: A Step-by-Guide to Applying ‘The Perspectives of Psychiatry’ (Chisolm & Lyketsos) comes in.

So, back to French cooking.  If any of you are into cooking, reading cookbooks, or just watching the Food Network, you may have heard of Auguste Escoffier’s 1903 Guide Culinaire.  Escoffier wrote his book for professionally trained and experienced European chefs (working in restaurants, hotels, ocean liners, private estates, etc).  Escoffier’s book outlined recipes and discussed methods of professional food preparation and kitchen management.  Escoffier did not offer his reader detailed recipes with instruction on basic cooking techniques, as he assumed the reader would already have this set of knowledge and skills.  His book’s target reader was not the average home cook looking for advice on how to keep a soufflé from falling.  Enter Julia Child and friends.  In Mastering the Art of French Cooking Julia Child et al translated a selection of Guide Culinaire recipes into simple steps and added detailed instruction on the basic techniques (How do you keep a soufflé from falling?  Ask Julia).  Julia Child’s goal was to start someone off in French cooking with the hope that someday they would be ready to go deeper and perhaps read the master himself. 

And so it is with Systematic Psychiatric Evaluation.  If you’re a clinician who already conducts a systematic psychiatric evaluation and are adept with applying the Perspectives approach to patients, there’s no need to read our book.  But, if you are new to the Perspectives and/or want to familiarize yourself with the model, we’ve got you covered.  Systematic Psychiatric Evaluation walks the reader through the basic concepts of The Perspective of Psychiatry and shows, step-by-step, how to apply these concepts to evaluate, formulate and develop individualized treatment plans for patients with psychiatric conditions.

Bon appétit!

Guest Post from Eric Stevenson: Caring for a chronic illness patient: A difficulty on its own

This Guest Post is from Eric Stevenson, a health and safety advocate who resides in the South Eastern US.

Having a chronic illness can be extremely tough, not only for the patient themselves but also for those who care for them. The process of loving and supporting someone with a chronic illness can be very difficult and challenging. Many times caregivers don’t want to speak up about their own stress because they may feel guilty or that it doesn’t matter as much than the patient’s problems. Luckily, there are a few ways to be prepared and help in the difficult situation of caring for a person with a chronic illness. 

There’s a great amount of social factors and possible coping strategies involved with care giving, as some things can influence stress levels in a positive or negative direction. Financial instability can cause major stress and mental issues for caregivers. In many times a chronic illness can lead to major financial problems as hospital bills continue to stack up. Financial factors can influence the mental state of caregivers in either direction. With more financial support, caregivers are often able to delegate some of their responsibilities, thus lowering stress and improving mental health. 

Social support also plays a huge role in the process of caring for a chronic illness patient. The help of family, friends, or even neighbors can play both a positive and negative part in the mental state. Not allowing for any support for the patient can often cause problems, but so can minimal support for yourself or a care giver. The stress and difficulty of taking care of someone with a chronic illness can be a major burden. Not having anyone to talk to or vent is often a major cursor to stress. 

Many people deal with side effects of coping strategies. Some may take to avoidance, but in many cases that will lead to further health problems. Avoidance as a coping strategy has been known to bring on many cases of depression. Many caregivers with low self esteem will use emotionally charged coping strategies, while those with high self esteem may turn to task centered coping methods. In the end, research has shown a large connection in self esteem and depression within caregivers. 

Factors such as the type of illness and location will also play a large part in the process. Some diseases like mesothelioma (a cancer forming from asbestos exposure) will have a severely low life expectancy. When compared to a patient that may be expected to live many years longer, the care giving situation will be extremely different. 

In the end, there are certainly a few factors that will play a large part in the role of a caregiver for those with chronic illnesses. The value of a support system and being educated on the disease will remain important. Caring can end up being extremely difficult and stressful, thus caregivers should also be looked out for in the future.

Stigma, Advocacy, and Having a Really Rough Time of it: From Guest Blogger Retriever

Roy wrote about the NAMI mental health report card by states, Maryland got a "B." The post got a heartfelt comment by Retriever, and I'm borrowing (with permission, and some minor typo editing) that comment to use as a guest post. Retriever writes:

Stigma limits advocacy. The main one is that patients who are trying to pass as normal-- to hold onto jobs or not embarrass their children-- can't lobby politicians, educate peers at work or at church, because, if they have a family to support, they can't risk outing themselves.

We have a kid who is autistic and bipolar. High functioning, but spent nearly a year when 8 psychotic, manic, a danger to himself and others, with no meds working at all for him. My husband was laid off from a job because his company would have had their insurance rates doubled if they continued to keep him on the payroll and insured, because of our kid's diagnoses. Mental health care is expensive.

People still judge mental illness, especially in kids. Social workers at least initially assume that the parents are abusing the kid. Neighbors and coworkers assume that the child is ill because of bad parenting. Parents would actually like to blame their own bad parenting because that is actually under one's control as, say, mania is not. They'd be happy if they could just go to a course to improve and Junior would stop seeing snakes and hearing voices.

People like cute, grateful pitiful victims to help. The reality is that people pass the hat to collect money for a piteously bald kid with leukemia and his family, but nobody ever passes the hat for a psychotic eight year old whom the hospital will not admit because (I quote) "your insurance will only pay us 60 per cent as their reasonable and customary charge, but DCF pays 100 percent. " Hence the kiddie psych unit having 95 per cent DCF kids.

Increasingly the move is towards care "in the community" and to closing public facilities like the state hospital that saved my kid's life (when manic and psychotic) because it would actually admit him and keep him there long enough until he was no longer a menace to himself. Where I live (one of the richest communities in the country) none of the private clinicians are willing to treat severely mentally ill children, so one is sent to a child guidance clinic which limits the care and usually provides it with cheap, relatively new social workers who can barely spell the name of the diagnosed condition let alone have any expertise in it.

And my state got a B.

I do what I can in our church, to educate the SS teachers about how to work with our many kids with various mental health issues (we are the most hospitable in the area to them, and bend over backwards to include them, provide one-on-one shadows, and make equal demands of them so that they are not marginalized--this approach was what most helped my kid). And I talk with parents of the newly diagnosed kids, and badger them to take the various special ed courses on how to do battle with the school system.

But it's a drop in the bucket. You can't talk openly about the truly appalling behaviors of your beloved kid, or people would never feel comfortable around them. You can't tell people why it makes you yourself hideously depressed. You dread any phone call from the school lest it be the dear sweet Buddhist teacher telling you that Junior (hypomanic despite meds tweaking) just told him to STFU.

Most of all you can't testify publicly, or write except anonymously or lobby or preach (I am a former minister) for real parity, and greater compassion for these reasons (to recap):

• The ill child (and their siblings) are entitled to anonymity. I am uncomfortable with all the mommies writing first person accounts with their real names. I wonder how their kids feel? It may be therapeutic to the mom, but could mortify and increase prejudice against the kids.

• Employers lay off people with high insurance costs, although they do not admit it. Sometimes, if one is a valued worker (as I have been), the employer will look the other way. But in cost cutting times, if one advocates publicly, the bean-counters at HR will find a way to get one axed.

• At least with pediatric psychiatry, the shrinks really don't know how bad it is or how much stress is on the family or the other kids caring for violent, manic, agitated kids at home. They don't care that spouses lose their jobs because of having to keep picking up an agitated kid from school, or stay up all night with one and getting too many phone calls at work from MDs.

Community care is like all the " I want a pony" stuff back when people abolished the snake pits in the fond hope of lovey dovey community group homes, etc for the mentally ill. In reality people said NMBY, there weren't the funds, and it is actually harder to prevent abuse and bad care in group homes than in large institutions.

Shrink Rap Meets Shrink Rap Radio

Dr Dave from Shrink Rap Radio interviewed us last week and posted it to his interview site, Shrink Rap Radio.  He asks us lots of questions, and we (characteristically) wander off topic.  There may even be a shocker in his podcast (no, just kidding).  [EDIT: Susan Argyelan has graciously transcribed the podcast for all to read (a pdf).]

Check out his extensive list of interviews, with many giants in the field (yes, that is a play on "shrinks").  We plan to have him on as a guest soon.  (And, yes, I am FINALLY getting our own podcast #46 to you today!  Sorry for the delay.)

My Three Shrinks Podcast 45: Guest Ray DePaulo on Treatment Resistant Depression

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We are pleased AGAIN to have the head of Johns Hopkins Psychiatry, Dr. J. Raymond DePaulo, joining us here to talk this week about treatment resistant depression (TRD), bipolar disorder, favorite quotes, and words we don't like.

Dr. DePaulo joined us on the last podcast (#44) and talked about cosmetic psychopharmacology, among other things.

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April 13, 2008: #45 Guest Dr. Ray DePaulo on Treatment-Resistant Depression

Topics include:

• Treatment-Resistant Depression. How is it defined (~10:00 min into the podcast)? Is there a magic bullet? Treatment strategies (don't give up; remember lithium; use proven agents; get 2nd and 3rd opinions; do psychotherapy).
  
  
• Nellie, the Hypothetical Patient. Let her know what we know about treatment, and what we don't.
  
  
• "Alternative" Treatments. St. John's wort; SAMe (s-adenosylmethionine); omega-3 fatty acids; ketamine; vagal nerve stimulation (VNS); deep brain stimulation (DBS); psychosurgery (cingulotomy).
  
  
• Cognitive Therapy. Many different types.
  
  
• Words which are Unliked by the Podcasters. Alternative treatment. Mood stabilizer. Antidepressant. Antipsychotic. Hallucinogen. Psychosis. Neurosis. Organic. Schizophrenia. Nervous breakdown. Mood Swings.
  
  
• Quotations We Like.
  "There's only two types of music: good music and bad music." Fran Liebowitz
  "Eighty percent of success is showing up." Woody Allen
  "Expect more of yourself and less of others; you'll be disappointed less." Unknown
  "Life is unfair; the sooner you figure that out, the happier you will be." Unknown (Lilya said it in 2003 on a recovery forum)
  "A good clinician is someone who makes prudent decisions based on insufficient information." Ray DePaulo (I think)
  "Experience is what we call it when we were looking for something else." Federico Fellini
  "Good decisions are based on experience. Experience is based on bad decisions." probably Mark Twain
  "'Experience' is simply the name we give our mistakes." Oscar Wilde
  "Science is a process of conjecturing and refuting what is thought to be universal, therefore a theory can only be considered 'scientific' if it is falsifiable," paraphrasing Karl Popper.
  "It's a short step from the penthouse to the outhouse." Unknown (many found)
  "It's a short step from Who's Who to Who's He." Unknown
  "There ain't no such thing as a free lunch," or TANSTAAFL, by Robert A. Heinlein.
  "When Momma ain't happy, no one's happy." Apparently, an old southern saying.
  "For every aphorism, there is an opposite aphorism that's equally true." Unknown
  "Children can be happy when their parents are miserable. But a parent is never happier than her unhappiest child." Laura Lippman
  "Data is not knowledge, and knowledge is certainly not wisdom." Unknown
  
  
• Drugs in the Drinking Water. Brief mention of last month's AP story finding all sorts of pharmaceuticals in numerous municipal water supplies.
  
  
• Books we are reading.
  -Ray: "Saint Augustine", by Garry Wills.
  -Roy: "Valis", by Philip K. Dick. (Ben was reading it on "Lost".)
  -Clink: More listening to an opera about Carmen, a famous female sociopath.
  -Dinah: "How Doctors Think", by Jerome Groopman.
  
  

Dr. DePaulo's most recent book is Understanding Depression.

There are three audiences for this authoritative book: people who think they may be depressed, those whose condition has already been diagnosed and are in treatment, and those who are concerned about someone who is either in treatment or probably needs to be.

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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. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Guest Blogger Dr. Gerald Klee on Martin Luther King Jr., Riots and Psychiatric Hospitalizations

Oh, I so wanted to put this up yesterday! A day late, but....

Dr. Klee writes:

Today, April 4, 2008, is the 40^th anniversary of the assassination of Martin Luther King, which was immediately followed by widespread rioting in cities throughout the US . Baltimore was one of the cities most seriously affected by riots. This tragic situation provided an opportunity to study how admissions to public mental hospitals would be affected by such an emergency. The following 1998 article from The Maryland Psychiatrist summarizes a report by Klee and Gorwitz in Mental Hygiene, Vol. 54, No. 3, July, 1970. The findings, though limited are quite interesting and counterintuitive. For example, psychiatric admission fell during the days of crisis, while General hospitals reported increased admissions of patients with delirium tremens during the same period.

It occurs to me that this story may still be relevant. How well prepared is our present health care system to handle the effects of future civil emergencies.

Riots and Mental Illness

by Gerald D. Klee, M.D. Editor

The Maryland Psychiatrist [Spring/Summer 1998; Vol. 25 No. 1]

Psychiatric Hospital Admissions During The Baltimore Riots of 1968

How would a widespread civil emergency affect psychiatric hospital admissions? Would they go up or down? Would there be differences in demographic characteristics or diagnoses of those admitted? Our efforts to make predictions may be more successful if we have access to biostatistical data from previous events.

The Baltimore Riots of 1968 provided an unusual opportunity to conduct such a study in Maryland.¹ Following the assassination of Dr. Martin Luther King, Jr. in April of 1968 there was rioting in more than 130 cities in the U.S. Baltimore was one of those most seriously affected, with widespread rioting, looting, and burning during the four-day period from Saturday, April 6th to Tuesday, April 9th. The National Guard was mobilized and a curfew was imposed in the city and adjacent areas. Many arrests were made. Daily life was affected in many ways for nearly all residents of the area, black, white, and others.

Events of this magnitude were bound to have many effects on mental health. Soon after the riots occurred, Klee and Gorwitz studied the effects they had on mental hospital admissions.¹

Summary of Methodology and Findings

Our data were obtained from the Maryland Psychiatric Case Register, a ten year (1961-1971) joint project between the Biostatistics branch of the National Institute of Mental Health and the Maryland Department of Mental Hygiene. I was the psychiatric consultant to the project. There was an active psychiatric advisory board with representation from the Maryland Psychiatric Society (MPS). With the exception of office visits to private psychiatrists, all psychiatric admissions and discharges in the State were reported to the Case Register. In this investigation, admissions from Baltimore City to the three state hospitals serving the area were studied. In addition to the four days of the riots, periods of two weeks preceding and following the riots were examined. The number of Baltimore City admissions during the two-week period before the onset of the disorders and after their conclusion did not differ markedly from comparable figures for the prior year (1967). There were distinct differences in admission patterns during the four-day emergency, however, both as compared with the preceding and the following time periods and also with the comparable period of 1967.

At that time, Maryland ’s psychiatric hospitals had been experiencing a consistent increase in admissions of approximately 10% per year. (The revolving door was already in motion.) While this pattern continued during the pre and post riot periods, there was a sharp drop in admissions during the four days of crisis. In 1967's comparable Saturday-Tuesday period, there was a total of 65 admissions to these hospitals. Adding the noted 10% increase brought the number of expected admissions to 71, but the actual number of admissions dropped to 50. Further variations were found on the basis of race and diagnosis as well as place of residence. While there were 27 black admissions for the four-day period in 1967, this decreased to 18 in 1968. The comparable figures for white residents were 38 and 32. Thus, while a drop in admissions was noted for both races, this decline was more marked for blacks. In 1968, 31 of the 50 patient admissions were diagnosed as alcoholic as compared with only 26 of the 65 admissions in the prior year.¹ Concurrently, there was a sharp decline in admissions with psychotic diagnoses (9 in 1968 versus 24 in 1967; statistically significant, using Chi-square test).

In 1967's comparable Saturday-Tuesday period, two thirds of the 65 admissions were from inner city areas where much of the rioting occurred in 1968. During the 4 days of disturbances, however, only half of the 50 admissions were from this part of the city. Some of the admissions were related to the civil disturbances. For example, some patients were picked up by the National Guard for violating curfew and were found to be mentally disturbed.

The data presented are one-dimensional and represent only a fraction of psychiatric episodes that may have occurred during this period. We have no information on the number of cases dealt with solely by the police and the jails. We did not examine short- and long-term mental health effects that did not result in treatment episodes.

While the sample in this study was small and not all of the comparisons were statistically significant, the results show interesting trends and are counterintuitive.

Comment

The study provides an interesting vignette of a major historical event in Maryland history. One would expect to observe changes in psychiatric admission rates during a widespread civil disturbance affecting nearly every aspect of life within the city. It is unlikely that anyone could have predicted a drop in admissions and the other changes that occurred. In hindsight, there are many possible explanations for the findings. For example, the rise in admissions of alcoholics was thought to be related to sudden curtailment of supplies of liquor as liquor stores and bars were closed. General hospitals reported increased admissions of patients with delirium tremens during the same period. Other civil emergencies may occur in the future. How well prepared will the psychiatric system be to deal with them?

1. Effects of the Baltimore Riots on Psychiatric Hospital Admissions; Gerald D. Klee, M.D. and Kurt Gorwitz, Sc.D.; Mental Hygiene, Vol. 54, No. 3, July, 1970

My Three Shrinks Podcast 44: Guest J. Raymond Depaulo MD

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We are pleased to have the head of Johns Hopkins Psychiatry, Dr. J. Raymond DePaulo, joining us here to talk about diagnoses, labels, and the ethics of using drugs to enhance one's cognitive skills (a fascinating discussion).

Dr. DePaulo joins us on the next podcast as well (#45) to talk about treatment-resistant depression, bipolar disorder, favorite quotes, and words we don't like. That should be up by April 6.

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March 30, 2008: #44 Guest Dr. Ray DePaulo

Topics include:

• NYT: The Ethics of Artificial Brain Enhancement, by Benedict Carey. On using cognitive enhancers, like Adderall, Vyvanse, and Provigil, to perform better. The article quotes NIDA's Nora Volkow, who wrote, "Even though stimulants and other cognitive enhancers are intended for legitimate clinical use, history predicts that greater availability will lead to an increase in diversion, misuse and abuse." Dr. DePaulo addresses the treatment of symptoms (eg, inattention in pilots) vs diagnoses, on the bases of functional impairment and subsequent consequences. Be sure to listen to the part around 24 minutes, where we discuss the ethics of a hypothetical drug that increases IQ by 30 points.
  
  
• Diagnosis in Psychiatry. Also some comments on ADHD vs Bipolar diagnosis, which led into an interesting discussion about the nature of diagnosing psychiatric "syndromes" in the absence of a definitive diagnostic aid, like a blood test or brain scan.
  Other references and topics mentioned by Dr DePaulo: Kraepelin. // Quote from Paul McHugh: "A good clinician in Psychiatry is someone who makes prudent decisions based on insufficient information." // Judy Rapoport's 1978 study of stimulants in normal kids. // The history of "ADHD" and "minimal brain dysfunction". // Labels and diagnoses. // William Styron // Kraepelin's Manic-Depressive Insanity.
  
  
• Prison Health Care. Clink compares correctional psychiatry capabilities with those in free society and wonders why care can be provided in jails and prisons yet we are the only country still without some sort of national health care.
  
  
• JAMA: Loss of Serendipity in Psychopharmacology, by Donald Klein. Article in the March 5 issue of JAMA. "This Commentary on the psychopharmacological revolution focuses on 2 mysteries: fostering medication discovery and finding out how they work."
  

Dr. DePaulo's most recent book is Understanding Depression.

There are three audiences for this authoritative book: people who think they may be depressed, those whose condition has already been diagnosed and are in treatment, and those who are concerned about someone who is either in treatment or probably needs to be.

Credit: At the end is a few seconds of "Manic Monday" by The Bangles [iTunes, Amazon].

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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. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Guest Blogger Dr. Peter Rabins on Deep Brain Stimulation

A while back we were talking about treatments for depression and some of our commenters asked about the newer, non-pharmacologic treatments out there. It was on my list, or maybe I was hoping Roy would jump in with some answers-- he likes gadgets and gizmos. We'd moved on and I forgot about this, but then we got an emailed request from JCAT in South Africa, asking for our thoughts on surgical treatments for depression, specifically Deep Brain Stimulation and Vagal Nerve Stimulation. I can't say I've ever recommended these treatments for any of my patients, I've never met anyone who has had them, and I don't have an opinion. I did, however, hear Dr. Peter Rabins talk about DBS as a treatment for depression last year, and so I thought I'd ask his opinion.

Dr. Rabins is a Professor of Psychiatry at Johns Hopkins Hospital where he is co-director of the division of Geriatric Psychiatry and Neuropsychiatry. He is the author of The 36-Hour Day, and more recently of Getting Old Without Getting Anxious.





Dr. Rabins writes:

There has been an amazing amount written in the popular
press about the potential for Deep Brain Stimulation
(DBS) to be usedto treat certain psychiatric syndromes.
Right now, there are preliminary and promising results
for severe, treatment-resistant major depression and
OCD but very little information has been published in
the peer-reviewed literature.

In Europe, DBS has also been used to treat anorexia 
nervosa,various substance abuse disorders, and even
aggressive behavior. Given what happened with
'lobotomy' surgery 60 years ago, I believe it is
incumbent upon the mental health community and
especially psychiatry to publicly and persistently
urge that the topic be approached from a scientific
point of view, that carefully designed studies with
long-term follow up data bemade publicly available,
and that very ill and vulnerable individuals be
protected from the harm and abuse that can result
from inappropriate claims, unnecessary and
non-beneficial surgery, and being taken advantage
of financially.

Many ethical and careful researchers have begun to
study DBS for psychiatric illness but it will take
time before results can tell us whether it is helpful
and worthwhile. In the meantime, it is best to keep
expectations down, to remind people that this is a
very expensive treatment that will likely only be
used for severe disease that has not responded to other
less invasive and less expensive approaches, and
that the treatments we have now for major depression,
including ECT,help the majority of very ill individuals.

My Three Shrinks Podcast 35: Shrinks on Film

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Last week, we had our guest, Dr. Mark Komrad, join us and begin to discuss the portrayal of psychiatrists in the movies. Mark used to have a live, two-hour, coast-to-coast, nationally syndicated talk radio show, and is a regular guest on NPR. He is also the Ask-a-Doctor on the NAMI site, and also has a book coming out. Mark was a guest blogger back in July, when he posted on Ethics and Continuing Education for the Psychiatrist.
This week Mark continues to discuss how Hollywood likes to portray psychiatrists in film. You can find him at www.komrad.yourmd.com. (Unfortunately, Monkey the parakeet gets sidelined in this podcast.)

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October 5, 2007: #35 Shrinks on Film


Topics include:

• Leona Helmsley's dog, Testamentary capacity, and Psychological Autopsies. ClinkShrink discusses how one starts to address the question of competency to being able to make the decsion to leave $12 million to one's dog. Bounty and one's natural heirs.
  
  
• Irv Schneider's 3 Psychiatric Archetypes: Doctors Dippy, Darling & Dangerous. These are the three categories of psychiatrists most frequently played in the movies and television.
  
  -Dr. Dippy: Bob Newhart Show; What About Bob? (Richard Dreyfuss); High Anxiety (Mel Brooks); Analyze This (Billy Crystal)
  
  -Dr. Darling: Equus (Richard Burton); The Sopranos (Dr. Melfi); Sixth Sense (Bruce Willis); Good Will Hunting (Robin Williams); Prince of Tides (Barbra Streisand); Ordinary People (Judd Hirsch); K-PAX (Jeff Bridges)
  
  -Dr. Dangerous: Silence of the Lambs (Anthony Hopkins); Terminator 2: Judgment Day (Dr. Silberman); Dressed to Kill (Michael Caine); Beauty and the Beast (Belle's father)
  
  See My Patient, Myself. How we must "neutralize" the negative images of psychiatrists in the media, "like your podcast." How the movie, Lovesick, affected the idea of psychiatrists falling in love with their patients.
  
  
  
• Psychiatric Services: Religion and Psychiatry. We have an interesting talk about the role that a physician's religious background may play in the likelihood of referring a patient with complicated grief to clergy versus a psychiatrist. See Roy's upcoming post on Religion and Psychiatry for more info. Briefly:
  
  -Psychiatric physicians were more likely to be Jewish or non-religious than nonpsychiatric physicians.
  
  -Protestant physicians were twice as likely as other physicians to refer the example patient to clergy rather than a psychiatrist.
  
  
  
• Washington Post on Virginia Tech: Roy briefly mentions his recent post on the final report on the Virginia Tech tragedy and the potential impacts on privacy of health care information, willingness of college students to get help, and liability. Dinah suggests readers go back to look at our prior posts about college mental health, Suicidal Students and Let's Talk About Suicide. This also led to a discussion about outpatient commitment.
  
  
  
• Correction: Dinah corrects her reference in Podcast 34 to Reign Over Me. The movie she was actually discussing was The Departed.
  

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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. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

My Three Shrinks Podcast 34: Guest Mark Komrad, MD

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This week we have a special guest, Dr. Mark Komrad, who is an old hat at discussing psychiatric issues on broadcast media. Mark had a live, two-hour, coast-to-coast, nationally syndicated talk radio show for about 5 years. He also had a regular gig on Channel 2 with Rudy Miller, and continues to be a regular guest on NPR. Mark is the Ask-a-Doctor on the NAMI site, and also has a book coming out. Mark was a guest blogger in July, when he posted on Ethics and Continuing Education for the Psychiatrist. (And Monkey the parakeet joins in.)

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September 26, 2007: #34 Guest Mark Komrad, MD


Topics include:

• Prison Tattoo Database. Clink informs us about Maryland's tattoo database.
  Dr. Komrad talks about Match.com's inclusion of tattoos in their matching database. We also talk a bit about the psychology of getting tattoos, in general.
  
  
  
  
• Q&A: I am a second-year medical student in Canada who is considering psychiatry. I have a few questions that hopefully you haven't already addressed elsewhere.
  
  Firstly, do you get many negative responses from other medical professionals and the general public for being psychiatrists. If so, how do you deal with it?
  
  Secondly, can you discuss some of the differences you know of in practicing psychiatry in Canada versus the US?
  
  
• Dr. Komrad discusses how he got into Psychiatry, and the images of Psychiatrists in the movies and in Hollywood. (Mentions Irving Goffman here.) Mark points out that only 3% of Americans have even been to a psychiatrist, and so most people learn about what Psychiatry is about from movies. Movies and shows discussed include The Sopranos, Dark Shadows, Beauty and the Beast, Prince of Tides... more on Podcast #35.
  
  
• Check out NAMI's Ask-the-Doctor column that Mark writes, also his website at komradmd.com.
  
  
• [Edit] Correction: Somewhere on the podcast, Dinah discusses a movie she incorrectly refers to as Reign Over Me. She meant to say The Departed.
  
  

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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. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

My Three Shrinks Podcast 32: Doctor Anonymous on Depression Overdiagnosis

[31] . . . [32] . . . [33] . . . [All]

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Today's podcast features a guest, Doctor Anonymous, who joined us via Skype. DrA is a midwest US primary care physician who blogs about medicine and health care. We've been trying to get him on for a while, but call schedules and such just didn't align. We both had Skype set up, I added Call Recorder (which allows you to easily record both sides of the conversation, each on a different channel), and it went off without a hitch.
DrIzzy from Michigan added a complimentary iTunes review (thank you), but he commented on our sound levels, which we agree are sometimes subpar. He points out that, since we have made the podcasting "big time" (LOL), we should get us some grown-up sound equipment. Now we are using a single Snowball microphone with the high-gain patch (mentioned in Podcast #3), which is sometimes doesn't pick up Clink and Dinah as well. So, we are thinking about getting a mixer and some lapel condenser mics. Let us know if any of you have suggestions about this. I'd like to add a couple Google ads on the sidebar to help pay for it; Dinah is equivocal. Let us know what you think. (Oh, the bird in the background is Monkey, my parakeet.)

Oh, and I see that DrA has started a call-in show! Check out the first one here.
-Roy

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September 2, 2007: #32 Doctor Anonymous on Depression Overdiagnosis



Topics include:

• DrA on Skype (not a soundboard). Dinah relished the memory of Podcast #24. Check out DrA's blog, doctoranonymous.blogspot.com.
  
  
• Is Depression Overdiagnosed? We discuss two point-counterpoint pieces in the August 18 2007 issue of BMJ (British Medical Journal). The YES piece is written by Gordon Parker, who believes there is a trend to turn "sadness" into a medical condition: "The ease of assigning a diagnosis of clinical depression, even of major depression, has rebounded on psychiatry, blunting clarification of causes and treatment specificity."
  
  The NO piece is written by Ian Hickie, who argues that despite the benefits of increased rates of diagnosis, many people with depression continue to go unrecognized, untreated, and impaired: "The increased rate of diagnosis has had other benefits, including reduced stigma, removal of structural impediments to employment and health benefits, increased access to life insurance, improved physical health outcomes, reduced secondary alcohol and drug misuse, and wider public understanding of the risks and benefits of coming forward for care."
  
  Find online comments on these articles at BMJ's website here.
  
  
• Further discussion about the symptoms of major depression, subsyndromal depression, dysthymia, substance abuse, the influence of the pharmaceutical industry, depression screening, access-to-care problems, inpatient bed capacity problems, per capita psychiatrists and psychologists, stigma about mental illness, primary care management of depression, emergency evaluations.
  
  
• We digress into hot McDonald's coffee, Twinkies, and chocolate.
  

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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. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.