Over On CPN and Novel Updates.

It's been all over the news that the psychiatrist who allegedly treated the alleged Aurora shooter had been disciplined by her state medical board for an infraction that occurred over a decade ago.  Is that relevant to this case?  I wrote my thoughts about this in an article for Clinical Psychiatry News.  If you're interested, please surf over there and read The Deep Dark Past of Dr. Lynn Fenton.   And while you're there, if you haven't already checked it out, read Clink's thoughts on Why the Mental Health Community Must Show Restraint. 

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On a cheerier note, I received the proofs yesterday for the paperback edition of Home Inspection.  There are a few issues, but the paperback should be available shortly.  And Double Billing is in the works.  If you've read it, please leave a review on Amazon.  And the Kindle edition is available for $2.99.  I'm taking Roy's advice and going with the cheapest price for now. 

Those Lying Psychiatrists

In the comment section of some of our blog posts, there have been comments about psychiatrists who lie.  While I haven't kept a tally of these remarks,  I think the most common assertion is that psychiatrists lie by telling patients they have to remain on medication for the rest of their lives.


My understanding of the term verb "to lie" is that it requires the person who utters a communication to know that it is not true, and it often is accompanied by a deceptive motive.  So, for example, if a patient has a UTI that can be treated with a cheap antibiotic taken for three days and the doctor knows this, but he is getting a kickback from the pharmaceutical agency and he's having trouble filling his schedule, so he prescribes the expensive antibiotic and tells the patient "You must remain on this for life, and you should come in for weekly visits or you will most certainly die," then this is a lie.


In medicine, we know very little for sure.  Every now and then we do know something absolute, like that if you do nothing about a specific condition, you will die.  What doesn't get said is that even if you do something about it, you may still die, and that no matter what, eventually you will die.


Doctors seldom know that you must do anything, when they say you must, or you should, or you need to, they are making a suggestion or recommendation based on the evidence that is available.  It's rare that evidence is complete.  You need to remain on this psychiatric medication for life is not any different in my book then You need to remain on a statin for life, or a blood pressure medication, or aspirin.  Maybe you have risk factors for coronary artery disease but it's possible you could live out your life without a statin without having cardiovascular disease, in which case you didn't "need" the statin.  Was your primary care doctor lying?  Of course, in the meantime, the statin could give you muscle problems, cause diabetes, or increase your risk of death by other means.  Oh, and while we're here, you "need a pap smear every year."  Oh, except now it's every 2 or 3 years, and not after 65.  Does every woman over 40 "need a mammogram?" Maybe it's 50?  Depends which agency you ask.  And don't start me on calcium, vitamin D supplements, yearly PSA measurements,  hormone replacement therapy, biphosphonates and all the other things we're told we "need" until it turns out they kill us. (Please note, there is nothing that currently indicates that vitamin D kills you and calcium only gives you increased risk for kidney stones, it doesn't kill you, and biphosphonates don't kill you unless perhaps they give you esophageal cancer).


When a patient is told they "need" a psychiatric medication for life, it's because the doctor believes the risk is high that the psychiatric disorder will recur without it.  Sometimes, it seems like a fair bet or that the risks are too high to chance NOT staying on a medicine.  Seven episodes of disabling major depression that caused the patient to lose their jobs, spouse, and have 4 hospitalizations and 3 serious suicide attempts?  Might not be a bad idea to stay on those meds, and you might not need such an extreme example to get there (I like to stay away from the lines).  


Sometimes, we're wrong -- after all, the recommendations are based on studies and statistics from groups of people with symptoms or illnesses, not on individuals.  The truth is that for most of these things, you don't know for sure until you try stopping them and see how you do without them.  But to call the doctor a Liar?  Isn't that going a bit far? Might be better to consult a fortune teller rather than a physician.

Frontier Psychiatrist

Please, someone explain this to me. 

PT: Psychotherapy "Alive and Talking"

This month's Psychiatric Times continues the discussion [registration required :-( ] about the NY Times article on psychotherapy that Dinah and readers discussed on April 9. This time, our colleague, Ron Pies MD, authored this article which deconstructs the myths perpetrated in the NYT article, which interviewed a med check doctor who found it "sad" that his patients found him to be important to them in their lives (read the article for the full flavor).

I'm glad that Ron pointed out (as we have) that the 2008 Mojtabai and Olfson article -- which implied that only 11% of US outpatient psychiatrists provide psychotherapy -- was a misleading statistic. Why? Because they did not consider brief psychotherapy sessions (30 minutes or less) to be classified as "psychotherapy" for their session. Thus, a 90807 (45-50 min) is considered psychotherapy, but a 90805 (20-30 min) would not be considered so, even though the AMA's CPT manual defines it as psychotherapy. Also, brief and supportive forms of psychotherapy are often given even when only a "med check" is billed. Nonetheless, the sound bite from that article has been: "Only 11% of psychiatrists do psychotherapy". It just ain't true. As Mark Twain said, "There are three kinds of lies: lies, damned lies and statistics."

Twitter Novel About a Psychiatrist and a Drug Company

So this is something different. A novel... by a psychiatrist... released 140 characters at a time via Twitter (@goosenovel). If you try to read it via Twitter, you have to start at the beginning, so it is easier to catch up by going to his novel site, for the twitter-impaired. It is written by Doug Bremner MD at Emory, who has already written a book about drug safety.

I thought the idea of a twitter novel was interesting (and surely Dinah will have something to say about this).

Shrinks, Shrinks, Everywhere!

I wanted a shrink-free day. I still haven't bought a new novel, but I'm getting there!

So I went to Washington this weekend-- it was rainy and muddy on the Mall, and there were people everywhere---long lines to get into the Archives and some of the more popular museums. We ended up at the Sackler Gallery checking out the Asian art. There's a photo of Arthur Sackler and I stop to read about him. You guessed it: he was a psychiatrist. There're everywhere.

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.

Normal People

I was talking to my med school roommate last night. She's a regular doctor, and she was talking about how they need more psychiatrists where she works. They're getting a new one soon, but he scratches his chin and he sounds a little twitchy. Someone said something about psychiatrists being weird. My friend said, "I know a normal psychiatrist." I asked her who, and she said "You" meaning me. I'm normal? Roy likes that people say we sound like "normal people" when they listen to our My Three Shrinks podcast. Roy actually looks like a normal person. ClinkShrink looks like a nun. I don't want to know what I look like. There are moments when I think I'm normal. When patients ask me if they're normal, I generally respond "What's normal?" Actually, I think I equate Normal with Boring. Maybe Normal people equate Normal with Sane? Most days, I'm pretty sure I'm sane, I'm positive that ClinkShrink is sane, and Roy...oh, Roy is sane and he even looks like a normal person.

So does psychiatry make people abnormal or are abnormal people attracted to psychiatry?

Let's try a few, feel free to add some of your own thoughts:

--People are often attracted to fields relevant to their own lives, so they are more likely to be interested in psychiatry if they have a mental illness or know someone with a mental illness. With the lifetime incidence of mental illness above 50%, I'm not sure this accounts for "weird." And many of my patients easily meet criteria for "Normal Person." This is the obvious response to why shrinks are weird, so it's where I started.

---One gets a little bonkers listening to people's problems all day. Maybe. I still enjoy it.

---Everyone knows shrinks are weird, so weird people join the club. I'm not sure how this explains the nun amongst us.

---Psychiatrists analyze everything and all that introspection makes you relate strangely to other people. There are probably some variants on this theme. It may account for unusual interpersonal styles, but not for chin scratching and twitchy-ness.

---Twitchy people can't hold scalpels steadily so they have to be psychiatrists. Good point.

So do 'normal people' have blogs?
And I still have to comment on ClinkShrink's last post Coming soon.

Loss of Psychiatric Beds on Vancouver Island

From the Nanaimo Daily News in Canada:

"VIHA said they had to shut the [psychiatric] unit for as long as a year because they cannot find a replacement for a departing psychiatrist. It's hard to believe that VIHA has allowed itself to end up in this position.

In fact, Alberni-Qualicum MLA Scott Fraser is right when he says, "It's not acceptable . . . . It's not an option. You cannot shut down essential services."

To add to Fraser's incredulity, closing a mental health ward approaches irresponsible if not outright negligent.

VIHA might argue they have no control over the comings and goings of doctors, but it's pretty hard to believe that they did not or could not foresee this long enough ago to take appropriate action.

Either way, the fact that they could not negotiate to have the current psychiatrist remain until a replacement could be found, or that they were caught by surprise, indicates something is wrong within VIHA.

What this also seems to indicate is that the health authority has little regard for those in need of mental health care."

This story says a lot about the way many hospitals view psychiatric treatment... as a community service that is somehow "optional."

My Creepy Shrink Is On the Wall Street Journal Blog

Check out the Wall Street Journal Health Blog-- Thanks to Scott Hensley for writing about those mean psychiatrists. Most aren't, just so you know. But Cruella.....

My 15 minutes of Blog Fame, though I am quite glad that Cruella is well-disguised.

The Shrink Rappers are off to APA. The blog may be quiet for a few days.

Note to my co-bloggers: Clink, all my emails to you bounce back. And I dropped my phone into the toilet tonight...the SIM card is saved and I could transfer it, so you can call me, but most of my numbers haven't transferred, and I haven't figured out how to text on the temp phone. Call if you need me.

When Hummingbirds Bonk

In cycling and running there's a phenomenon known as "bonking". Bonking is when you just suddenly get overcome by exhaustion and you collapse. To be scientific about it, you 'deplete glycogen stores' and can't go on. A friend of mine tells me that this happens to hummingbirds. They can be found collapsed on the ground, exhausted, which isn't too surprising for a creature whose heart beats up to a thousand times a minute. Fortunately they can be revived with a little sugar water.

There are days when I can really identify with those little guys. On days when I see twenty-plus patients, when everyone is in crisis, when I just can't seem to find a chart (or the medication nurse can't find my order), at some point you hit the wall and bonk. It's that moment when I think to myself that I will just walk out of the facility and never come back.

Unfortunately, sugar water just doesn't do it for me.

This is what to do to revive a correctional psychiatrist in case you ever find one lying on the ground, exhausted, with a heart rate somewhat lower than a thousand beats a minute:

Administer coffee immediately, followed by judicious amounts of dark Belgian chocolate. Don't worry about checking for consciousness first, just hit the Starbucks.

If this doesn't work consider depositing a large, warm, furry and loudly purring cat on the psychiatrist's stomach. This is also a test for consciousness since those tiny sharp kneading claws are bound to get a reaction.

Once revived, deposit the psychiatrist in the middle of a large quiet forest with miles of hiking trails (trail map included). Allow time for staring up at tree branches, listening to the wind whistle, admiring large fungi and searching the stream for minnows.

Repeat, ad infinitum, until smiles return.

I suspect every psychiatrist has their own particular favorite ways to recover from the hummingbird bonk. Dinah is relaxing in a warm, sunny place and Roy seems to find comfort in buying new very large computer monitors (I'm jealous). Regardless of the recovery method, we will all find our way back to Shrink Rap eventually.

Roy's Top 10 Search Phrases of 2007

Like I did last year, I scanned through the search terms that people googled to get to one of our blog pages, and here is the list of my top 10 search phrases for 2007 (based solely on those I found funny, interesting, or just bizarre).

10. is being a psychiatrist fun?
9. feline mental disorder ... I think that was the catatonia pun
8. funny dr phil fake interview ... if you haven't heard our prank on Dinah, listen here
7. freud the meerkat
6. how do I stop my best friend from listening to rap ... hopefully not Shrink Rap
5. worried but well ICD9 code
4. how to tell someone to stop talking
3. nobody ever called pablo picasso an asshole
2. how does a shrink order a salad
1. why oompaloompas are scary

Be sure to also check out the Top 25 Shrink Rap Posts of 2007.

Top 25 Shrink Rap Posts for 2007

Happy New Year!!

Last year at this time, we gave you a Top 25 Posts of 2006 list, so we give you this year's countdown list now. (Yes, I will also do a Roy's Favorite Search Phrases of 2007, like I did last year.)


Last year, our main blog page had 27,809 page views, with 9991 "absolute unique visitors" (we started in April 2006, so last year was not a full year). In 2007, the main page had 70,166 views (173,444 page views for the entire site) and 67,867 absolute unique visitors. Thank you for your interest in Shrink Rap!

Last year our #1 post was Stopping the Scourge of P.E. (my post, as DrivingMissMolly pointed out). This year it is again one of mine, so I am challenging my co-bloggers to out-post me in 2008 (if you can...lol...jk).

Rank	Page- views	Blog Post
25	579	The Well-Worried Well
24	583	Who Wants to be a Psychiatrist?
23	586	Roy's Top 10 Search Phrases of 2006
22	586	Personality Disorder?: Chloe O'Brian from "24"
21	598	The Co$t of Being Depressed
20	619	Transference To The Blog [a 2006 post]
19	673	Depakote & Ammonia
18	689	How This Shrink Picks A Sleep Medication
17	694	My Three Shrinks Podcast 1
16	696	Walk Like A Psychiatrist
15	713	FDA Drugs: February 2007
14	725	Put Down the Duckie: A Psychotherapeutic Study
13	733	What To Get Your Psychiatrist For Christmas, Hanukkah, or Kwanzaa
12	733	FDA Drugs: November 2006
11	736	True Confessions [a 2006 post]
10	951	What's Your Favorite SSRI?
9	968	Sex With Fish [a 2006 post]
8	1179	How A Shrink Picks An Anti-Depressant
7	1184	SSRI Antidepressants & Violence
6	1377	What People Talk About In Therapy [a 2006 post]
5	1451	Ritalin or Abilify for I.V. Amphetamine Dependence
4	1901	Roy: Psych Notes for Smilies [a 2006 post]
3	2303	Why I Still Prescribe Seroquel
2	2391	Grand Rounds at Shrink Rap!
1	5987	Why Docs Don't Like Xanax (some of us)

Where Do Tests Come From?

I'm writing this post in followup to my previous post "How This Psychiatrist Thinks About Psychological Tests". In that post I wrote about the different types of psychological tests and why psychiatrists and psychologists use them. In this post I'm going to talk about how psychological tests get invented.

It's always something I thought would be a great gig to have: invent a psychological test, get a copyright, make sure it's good for something, then set up nationwide seminars to train and certify people to use it and sell the test to them. Talk about a self-made entrepreneur!

But there's a reason why everybody isn't doing this. It's because inventing a test---I mean one that is actually meaningful and useful---is actually quite hard to do. Drug companies spend loads of money inventing new drugs only to have them go down in flames during the clinical trials; the same thing happens with psychological tests.

To illustrate the process, let's imagine that we are going to invent a test that would be useful to the blog. We want a tool that will measure the degree to which a post (or blogger, or podcast guest) will entertain a reader or listener. Let's call it the Shrink Rap Silliness Inventory (SRSI).

The first thing you do is scour the literature looking for existing tests that are supposed to do what you want. In our case, there is nothing out there already in use that measures silliness. If we found such a test we'd look at the research behind the test to see what we presently know about the silliness measuring business. This literature review might tell us that there are various characteristics that are indicators of silliness: a tendency to wear big floppy shoes, to talk in a funny voice, to be a Monty Python fan, or to be named Roy (sorry Roy, couldn't resist). We'd use this information to put together the items used in the SRSI. The items might be questions that the subject/patient has to answer (eg. "Is your name Roy?") or observations that the test administrator makes (eg. "On a scale of 1 to 7, how big and floppy are this subject's shoes?"). Once you have a series of experimental test items put together, you're ready to start taking your SRSI for a test run (pardon the pun) to see how well it works.

The first thing you have to figure out is whether or not the test actually measures what you want it to measure---this is known as validity. We want the SRSI to measure silliness when it's present and to rule out subjects who aren't silly. In order to do this you have to give your test to groups of people known to be silly and others who aren't, and compare their scores. If SRSI scores are high for known silly folks (say, students at the local clown college or improv group) and low for non-silly folks (maybe your local newscasters) then this suggests your test is valid because it can distinguish between groups. This is analogous to using a medical laboratory test to distinguish between diseased and healthy people. There are other ways of proving test validity, but this is the usual starting point.

The second thing you have to prove is test reliability. In other words, that you can trust the test to measure things stably over time. We want the SRSI to work every time, like a car that will start in cold weather. You check for this by giving the test repeatedly to the same person or group of people over time and comparing their scores. Since we know silliness is always consistent, we want SRSI scores to be stable too---this is known as test-retest reliability. We also want lots of people to be able to use the test and have it work well for all of them. So we give the SRSI to a lot of people and have them each rate the same subject. If the SRSI scores all turn out the same we know our test has good inter-rater reliability.

Finally, you want to know how likely it is that your test score is going to be wrong. There are two ways a test score could be wrong: if a silly person gets a low SRSI score that would be an error known as a false negative test; if a non-silly person gets a high score that's a false positive test. We would have to look at our test data and figure out the percentage of times the SRSI gets a wrong score, either false positive or false negative.

This is just a portion of the research that has to go into inventing a good psychological or medical test. If we manage to jump through all these hurdles then you'd go on to do research to see if the test actually gives us useful information----if podcast guests with high SRSI scores give us better iTunes ratings and downloads, or higher visitor counts on days when they guest blog. We could even have SRSI scores for each of us Shrink Rappers! But I guess that comes back to my original issue with psychological tests---I don't need a test to tell me that Roy would be silliest.

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(Alright, you have to admit that inkblot looks like a pelvis. I can't be the only one seeing body parts here.)

How This Psychiatrist Thinks About Psychological Tests

First a big thank you to Gerbil for giving me the idea for this post. In a comment on my post "What Good Are Psychologists?" she mentioned psychiatrists who refer patients for diagnostic psychological testing. It got me thinking---this is a good thing---about why I do (or don't do) what I do.

I have to say I hardly ever request psychological tests. Even before I started working in prison, it just wasn't something I routinely did with my patients. When I was in residency we had lectures from psychologists about the different types of tests and what they're indicated for and a few things about interpretation, and later psychologists I've worked with have told me that I have a better understanding of testing than the average psychiatrist, but I'm not sure what that means.

For the lay readers among us, there are some general categories of psychological tests. There are personality tests that measures different character traits. There are intelligence tests that measure IQ. There are projective tests that are used to get an understanding of the person's interpersonal dynamics and style of thinking. There are neuropsychological tests that measure a person's cognitive capacity---ability to learn and remember, use language, coordinate eye-hand movements and so forth.

In general, when thinking about tests you have to consider what it is you're trying to figure out. If you have a patient who is failing in school you might want to order IQ or other achievement tests to see if the personal has a developmental disability or learning disability. If the patient has had a head injury or you think he or she might be getting demented you'd order neuropsychological testing. If you have a patient in therapy and you want material that might be useful to help the patient understand his own inner workings, you'd request projective testing and/or personality testing. Some tests are used as tools to predict certain things: whether or not someone would perform well on a certain job or whether or not they will re-offend as criminals.

It's important for tests to be used as part of an overall patient assessment. Test results fit into a whole database of information that a psychiatrist considers when making a diagnosis or putting together a treatment plan, in addition to a good patient history and a review of available treatment records.

It's also important to know whether or not the given test has been validated for your particular patient because 'normal' test results can be different for different groups of people. A test is only as good as the patients it's been based upon. For example, normal results for the original Minnesota Multiphasic Personality Inventory (MMPI, a test used to diagnose psychiatric disorders) was originally based upon only 500 people living in Minnesota. Much as I would like to think that Minnesota should be the gold standard for normalcy, this just isn't realistic. I mean really---Baltimoreans would end up looking pretty depressed compared to them. This is where a big limitation comes into play for me working in prison---many psychological tests have not been validated for use in prisoners.

Similarly, predictive tests only give group predictions and aren't necessarily reliable for the individual. A certain score on the Hare Psychopathy Checklist might give you a result that the patient has a 15% chance of re-offending, but that just means that out of 100 people with an identical score 85 will not re-offend and 15 will. The score doesn't tell you which of the two groups your patient will actually be in. The other trick with using tests to predict things is that many tests used for prediction have never been proven to have predictive value---there is no test to predict 'good parenthood', for example, yet psychological tests are used constantly in custody evaluations. It's important to know the limits of the test.

So...which tests do I actually use?

In prison the most common test I use is the Mini-Mental State Examination (MMSE). It was invented by two psychiatrists as a quick bedside test of cognitive functioning. You can give it in about ten minutes and it's a great way of measuring how brain impairment changes over time. You use it to check to see if someone's delirium is resolving, or as a screening tool for problems that should be investigated further.

In free society the most common tests I used, besides the MMSE, were general symptom inventories. For example, the Beck Depression Inventory (BDI) is a nice tool for measuring the severity of depressive symptoms. It's used to screen people for depression and also to monitor reponse to treatment.

I never use projective testing, mainly because I've never found it particularly useful for anything---maybe I would if I had a psychotherapy practice but even then I don't know too many psychiatrists who use them. I'd probably use neuropsychological tests if I could, but these are very specialized tests that have to be administered by a neuropsychologist (a subspecialty of psychology) and I don't know of any prisons who have one of those.

So that's my take on psychological tests. Thanks, Gerbil.

Neuroscience Funding Gets A Boost

Just a couple weeks ago the Justine and Catherine MacArthur Foundation awarded a $10 million dollar grant to twelve universities to study neuroimaging and the law. The purpose of the grant is to get a better understanding of the relationship between functional neuroimaging studies and forensic issues such as competence to make decisions, criminal responsibiity and disabiity. This grant has the potential to really change the nature of psychiatric expert testimony.

The grant has three components: brain abnormalities, substance abuse and decision-making. There will be some overlap between these areas, but the general idea is to start bridging the gap between what is seen on a functional MRI and the ultimate legal questions of criminal culpability and competence. This can be a life or death question---in Roper v Simmons neuroimaging was used as evidence that juveniles should not be given the death penalty. Hopefully the MacArthur grant will shed some light on whether the degree of brain myelination in juveniles is, in fact, relevant at all to criminal responsibility. Right now the legal opinions based on neuroimaging have tended to leap a bit beyond what science has shown in my opinion.

What I Learned Part 3

The final installment in my conference series. Tomorrow I come home to my fellow bloggers! I miss them.

• In France they are doing an interesting project to look at the effects of incarceration. They are asking prisoners to spontaneously describe their incarceration experience and how they think it has affected them, then they are using computerized lexicographical analysis to define common domains of concern.

• There was a poster looking at the neuroanatomical basis of empathy, sympathy and moral reasoning. Highly theoretical and completely lacking in data, unfortunately.

• In 1895 Bridget Cleary was burned to death by her husband, who believed that she had been kidnapped by fairies and a changeling left in her place. It is possible that Michael Cleary suffered from a form of Capgras delusion.

• Someone tried to do a study looking at treatment compliance and motivation for change in sex offenders, but there weren't enough sex offenders motivated to participate in the research.

• Very few states have laws requiring mandatory reporting of impaired drivers to the MVA.

• One Russian psychiatrist proposed that the term "dependent behavior disorder" be used as a diagnosis for a broad range of compulsive behaviors.

• The first documented use of telepsychiatry was in 1959. In the U.K. a criminal justice statute required the installation of teleconferencing equipment throughout the courts and correctional facilities in the country. This is now being used to perform clinical and court-ordered psychiatric assessments. Free society studies have shown patient satisfaction to be similar between telepsychiatry evaluations and face-to-face interviews. In the U.S. there are a number of undefined legal issues with regard to telepsychiatry and computer-assisted treatment. These including licensing issues for practice across state lines, informed consent for remote clients/patients and malpractice coverage across state lines.

• Directors of forensic fellowship training are working to create measurement tools and procedures to meet the core competency requirements of the American Council for Graduate Medical Education (ACGME). There was a very nice workshop that presented a "toolbox" of techniques for documenting residents' competency as well as a discussion regarding how to prepare for an accreditation visit. The workshop also discussed the challenges of funding a forensic fellowship program.

THE END

Thank you for reading

What I Learned Part 2

Here's the second installment in my conference ramblings:

• The Supreme Court decided in Sutton vs. United Airlines that for the purposes of the Americans with Disabilites Act the disability must be assessed only after attempts have been made to correct the impairment.
  

• Liability in medication-related tort claims is best reduced by well-documented informed consent (Duh. But that came up a lot this year so I mention it.)

• In states that allow for outpatient commitment, only 20% of pretrial detainees who are referred for commitment actually end up getting commitment orders. This is because most of them are either sent to prison prior to a commitment hearing or because they are committed to a hospital for restoration to competence prior to an outpatient commitment hearing.

• Death Penalty

In 2006 there were 53 people executed, 32 were white and 21 were black. In 2005 there were 1805 whites and 1372 blacks on death row. One out of 12 death row inmates had committed previous homicides. Death penalty aggravating and mitigating factors are set by state statute. Aggravating factors include victim characteristics (law enforcement or firefighting personnel, children, pregnant women), defendant characteristics (previous violent offenses), and offense characteristics (murder committed during the course of a felony, contract killings). By law all possible mitigating evidence is allowed to be heard during the sentencing phase of a death penalty proceeding. Although mental health issues are statutory mitigating factors, sentencing juries actually consider them as aggravators and they are more likely to result in a death sentence. The main purpose of expert mental health testimony in a death penalty hearing is to humanize the defendant and to change the focus of the hearing from the crime to the defendant. It also serves to give the defendant an opportunity to communicate to the jury through the expert. Surveyed death penalty defense attorneys usually prefer psychiatrist rather than psychologist expert testimony. They prefer forensically trained experts with an area of expertise that is relevant to the case, with good testifying skills.

• Risk Assessment in the U.K.

The U.K. has a relatively new law that allows for the indefinite detention and/or community supervision of violent offenders. This led to the creation of the Risk Management Authority, an administrative body that trains, supervises and regulates official risk management assessors. The assessments are quite exhaustive and includes a minimum 6 hour interview over three days. It is primarily a clinical assessment although it does require the use of at least one "official" approved actuarial tool. There were only 7 orders for assessments filed in 2006. Some offenders refuse to cooperate since they know it could result in a lifetime of supervision and mandatory treatment.

Another development was the creation of a Dangerous and Severe Personality Disorder Service, which essentially is a tool for civil commitment of psychopaths. This has led to 150 referrals a month and an increased number of non-mentally ill sociopaths in forensic hospitals. (One presenter's quote: "The system is swamped.") They are treated with cognitive-behavioral therapy at a cost of $500,000 per inmate per year. Remarkably, there have only been three minor inpatient assaults involving these patients over five years.

• Liability and risk management in forensic practice

Case law is still defining areas of liability for forensic clinicians. Most liability seems to arise as a result of independent medical evaluations (IME's). The 2006 case Harris v. Kreutzer determined that there was a limited physician-patient relationship created during the IME. The three duties created as a result of this are: 1) to cause no injury during the evaluation (read the Harris case), 2) disclose significant findings to the evaluee (eg. an orthopedic surgeon doing an IME who incidentally discovers a tumor), 3) maintain confidentiality (eg HIPAA compliance)

Most states have limited civil immunity for expert testimony but this is not absolute & varies with jurisdiction. Experts appointed by medical boards for peer review have been sued with varying degrees of success by their evaluees. A forensic expert could face discipline from the AMA, the state medical board, or a specialty organization. In general psychiatric practice most liability comes from suicide or from medication-related injuries.

• Ethics of Forensic Psychiatry

In 1982 Harvard professor Dr. Alan Stone gave an address in which he suggested that it was unethical for psychiatrists to be involved in expert testimony. The last panel today was an update by Dr. Stone on his position and a response from a number of illustrious colleagues. I can only give this topic pitiful recapitulation here. Stone argued that psychiatry has no absolute truths to offer and that professional consensus is dangerously misleading. Panelists Ezra Griffith, Stephen Morse and Paul Appelbaum responded that it is ethical for professionals to aid the court's search for truth and to promote justice. While acknowledging potential ethical pitfalls, there was a consensus that evolving standards of science provide something to offer.

(Incidentally, in Podcast #14 (No April Fool) I talked about the New York Times article, Brain On The Stand, which quotes Dr. Morse's views on the use of neuroimaging in forensics. Now that I've had a chance to listen to this guy speak it is clear that he is someone to keep an eye on. Interesting things are going to be coming out of U. Penn, particularly with his involvement in the recent $10 million MacArthur grant for neuroscience and the law. This is probably worth a blog post all on its own, when I get the chance. Right now I'm off to dinner.)

What I Learned Part 1

This is my second annual blog post that summarizes my experiences at the forensic conference I attend every year. Last year I put up a three part "What I Learned" series, which I occasionally go back to when questions come up and I know I heard something about it once but can't remember the details.

So here goes:

• The Atlantic ocean is surprisingly warm for October.
• There are approximately 5000 women murdered every year in honor killings. Syria and Jordan still have laws on the books for men to kill their wives without consequences if they are caught in the act of adultery.
• There is evidence that the Slater method may be effective for restoring developmentally disabled defendants to competence to stand trial.
• Only two states in the country (Connecticut and Indiana) have laws that allow police to seize legally owned weapons from dangerous individuals.
• Violence predictions instruments, even the PCL-R, has not been validated for use with women and it is not recommended to use them as a predictive tool for female defendants or prisoners.
• Vaginal plethysmography exists but has not been validated for use in evaluating female sex offenders.
• In recent years the number of women found Not Guilty By Reason of Insanity (NGBRI) has increased. This may be due to increased awareness of post-partum psychiatric illness.
• Culture-bound syndromes can be seen in immigrant populations and it is necessary to understand these phenomena in order to distinguish them from delusions. Ashanti witchcraft, "root workers" and others may lead to commonly held cultural beliefs.
• A woman named Marti Ripoli was an infamous serial killer in the nineteenth century. She was thought to be responsible for the deaths of 25 children, whose blood she used to make magical remedies that she sold on the streets. Belle Gunness had nothing on this lady.
• Alan Felthous gave an amazing Presidential Address in which he reviewed the religious and philosophical underpinnings of free will from Aristotle up to the neuroanatomy of decision-making as shown by functional MRI's. All in less than an hour. Wow.
• There was a great panel presentation about cults. They discussed the difference between a religion, a sect and a cult. They described characteristics of cult leaders and followers and cult dynamics including recruitment, retention and deprogramming. They presented case law regarding deprogramming practices and risk management issues for psychiatrists. Finally, they presented the satanic cult abuse issues of the 1980's and the lessons learned from this. (I enjoyed the tutorial about the Church of Satan and what to ask your Goth patients. Also the Church of Satan tattoos. Personally, if I saw a 'Satan Rules' tattoo I don't think I'd need to ask too many more questions.)
• In Germany forensic experts are always the agents of the court rather than agents of an adversarial attorney. The goal is a neutral and impartial evaluation. (We could learn something from that here in the States. I bet their malpractice costs are significantly lower.)
• The concealed information test is the most commonly used experimental deception paradigm. It has been used in functional MRI lie detection studies, the first one of which was published in 2001. The number of fMRI lie detection studies has increased quickly since then, but a number of the authors are partners in two companies that do commercial fMRI lie detection, Cephos and No Lie MRI. (We discussed this topic in Podcast 5: Sex, Lies and Neuroeconomics.) Functional MRI's cost about $1800.
  
• SPECT scans are very sensitive but completely nonspecific. They are abnormal in a broad variety of conditions but there is a lot of overlap between conditions. When using SPECT to evaluate mild traumatic brain injury, it is important to first rule out the confounding variable of clinical depression.
• Problematic Internet use covers a broad range of behaviors: cyberstalking, cyberbullying, excessive surfing, excessive online gaming and inappropriate work behavior.
• When evaluating a building for Sick Building Syndrome it is important to do a visual inspection first, then take samples if necessary. Sampling includes measurements of wall and room humidity, temperature, carbon monoxide and carbon dioxide levels and surface swabs. A normal carbon dioxide level is 1000 parts per million. Normal building temperature is from 68-72 degrees in the wintertime with less than 60% humidity. Some plaintiffs alleging sick building syndrome are actually suffering from somatization disorder so it may be necessary to involve forensic psychiatrists in these evaluations.

PHEW. And that's only the first day. Here's the other thing that I learned:

I love eating lobster while watching the ocean. Beats the heck out of working in prison.

Virginia Report: Not Enough Psychiatrists, Beds

The Washington Post reports today on a 230-page state report that finds Virginia "lacks experienced psychiatrists to evaluate the mentally ill, there aren't enough beds for those seeking emergency treatment in many areas and hospitals are losing money on mentally ill patients, according to a state government report."

Last year, NAMI released a Report Card for each state, grading them on things like access to care, services, and infrastructure. Virginia received a grade of D. Today's report suggests increasing funding to meet the state's need.

"Additional psychiatric beds cannot be opened unless there are psychiatrists available and willing to staff them," the report says. It adds: "On the outpatient side . . . a lack of psychiatrists affects licensed hospitals because individuals in need of psychiatric service cannot find them in the community and . . . turn to emergency departments. . .

To address these shortfalls, the report suggests that the state "examine its potential role in . . . assuring an adequate supply of beds . . . [by] increasing financial support for uninsured psychiatric patients."

NAMI's report noted the lack of culturally competent treatment, and rights abuses in some of the state hospitals.

"Additionally, Virginia's ability to serve its growing population of ethnic and racial minorities has suffered because the state has shown no initiative on the issueof cultural competency. Virginia has not conducted a cultural competency assessment or developed a plan to meet the needs of minorities, who comprise nearly 30 percent of the state's total population.

Lack of short-term acute care beds for individuals in crisis is another major problem. In Northern Virginia, the commonwealth's most populous area, approximately 24 percent of the region's private bed capacity vanished in 2005 alone, due mostly to the closure of psychiatric wards at four different hospitals. Individuals in need of beds are transported downstate, resulting in trauma for the individual and diversion of local police officers, who must spend hours transporting people to areas as far away as Hampton Roads.

State hospitals have posed a different set of issues. In the 1990s, four out of 10 were under investigation by the U.S, Department of Justice (DOJ) for egregious violations of the rights of patients."

To view the actual report, the 230-page pdf report is here, and the briefing, consisting of 60 slides, is here.