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. 

Pink Boys

There was an interesting article in the Sunday New York Times Magazine on children who behave in ways that are inconsistent with the gender role expectations society holds for them.  The article starts by talking about a mom who e-mails the other parents in the  pre-school  to let them know their son is 'gender-fluid' and will be coming to school in a dress the first day.  

I spent a little more than a decade as a consultant to the Johns Hopkins Sexual Behaviors Consultation Unit (SBCU).  I also spent a few months working as a resident on an inpatient unit for people with sexual disorders-- though the two systems were completely different entities back then.  What differentiated whether a patient went to one versus the other was often a matter of legal involvement: someone who's sexual behaviors got them into legal difficulties (often people with pedophilia) were the domain of the Sexual Disorders group (they also had an outpatient component but I never worked there) and treatment sometimes included hormone injections to lower the patient's sex drive, along with individual and group therapy.  No one was admitted to this unit involuntarily, and no one was given hormones involuntarily.  The two units have since merged, but there is no longer an inpatient unit, it's all outpatient consultation.  Even back then, treating people with pedophilia was a logistically difficult thing: if a patient went to a psychiatrist and said "I've done this awful thing and I want to stop," it had to be reported (it still does) and there is no mechanism for getting help unless the patient requests it prior to acting on such urges, or after he's been caught and the assessment/treatment are part of his legal stipulation or defense. 

The SBCU  saw people with erectile dysfunction, couples with mismatched sexual drives, people who had troubles with all aspects of the sexual cycle (desire, arousal, climax, etc), those with fetishes,  and those with concerns about gender.  "Pink boys," a term I've never heard, would fall under that category.   Back then (the 1990's, early 2000's) the mentors of the unit felt that parents should encourage  their children to adopt gender-appropriate behaviors and play.  There was some thought that permissiveness around allowing Johnny to have a Barbie collection might encourage such things.  

In "What's So Bad About a Boy Who Wants to Wear a Dress"  Ruth Pawdawer, states:

Many parents and clinicians now reject corrective therapy, making this the first generation to allow boys to openly play and dress (to varying degrees) in ways previously restricted to girls — to exist in what one psychologist called “that middle space” between traditional boyhood and traditional girlhood. These parents have drawn courage from a burgeoning Internet community of like-minded folk whose sons identify as boys but wear tiaras and tote unicorn backpacks. Even transgender people preserve the traditional binary gender division: born in one and belonging in the other. But the parents of boys in that middle space argue that gender is a spectrum rather than two opposing categories, neither of which any real man or woman precisely fits. 

Twenty years ago I wasn't comfortable with the way psychiatry approached this topic.  I didn't believe that a child's gender role choices were necessarily 'choices' or that parenting styles (at least those those with-in some spectrum of "normal"), caused children to want gender-inappropriate dress/toys/identities.  The question remains, if this is who you are, shouldn't you come to some comfortable acceptance with yourself?  Unfortunately, our world is such that when a boy shows up at school in his princess outfit, other children might not want to play with him, and it can all make for a very confused, painful, and uncomfortable life, so professionals who encourage gender-appropriate roles aren't being mean or stupid or evil, they are just trying to figure out (with the benefit of a crystal ball) what will lead to the best result.  And this all occurs where both the individual involved may be fluid with their gender role (some pink boys turn blue), and society is fluid with it's acceptance of everything from left-handedness, to homosexuality, to it's stigmatization of cigarette smokers.  

 Around that time, my next door neighbor called me to ask if my son would like to take ballet lessons with her daughter (she was 2, he was 3 and they were best friends).  I asked my son, "Do you want to take ballet lessons with your friend?"  The 3-year-old considered this for a moment and said, "Is that a girl thing?  Do they have baseball lessons?" I don't think it was about parenting -- I would have sent him to ballet and assumed is was just another activity with a friend -- I think it was in his brain that made the girlthings-boythings distinction.

Interestingly, girls don't have these issues.  There are "girly-girls" with their interest in fairies and princesses, and there are tomboys who wouldn't be caught dead in a ballerina outfit.  We don't tend to worry about girls, and playgrounds  have the tomboys playing soccer on one side while the girly-girls play fairy princess on the other.  

The point of the article was that there are people who are struggling to deal with their children's gender issues -- it was more about the parents then the kids --  and while there are still no clear answers for what makes the happiest, most well-adjusted kid, there are those who believe that it's better to help a child accept who he is.

We now leave left-handers alone.  The Greeks were fine with their pedophiles.  Our society shuns them, more so then murderers.  Despite our growing rates of obesity, we still blame and ostracize those who are fat: shouldn't we teach people to eat and exercise in a healthy fashion, and beyond that to accept themselves with the awareness that people come in all sizes? And don't get me started on Presidential candidates.

I have no answers, I'll let you chime in.

Here's a link to the Hopkins Sexual Behaviors Consultation Unit. They list the conditions they treat and a phone number to schedule an assessment.  
Dr. Chris Kraft, their director of clinical services, has been a podcast guest with us on several occasions, see:
Podcast #21 Chris Kraft on Gender Issues
Podcast #41 Chris Kraft on Conversion Therapy 

Oh To Be Mentally Ill

We talk about the mentally ill as though they are a defined class of people.  The mentally ill need this or that...  The mentally ill live shorter lives.... need different resources...are dangerous...are not dangerous...smoke more...eat less chocolate... whatever....


So who are these mentally ill people?  And what do we mean when we speak of "the mentally ill?"  Community based studies showed many people-- I'm thinking the number is 56%- have a lifetime prevalence for psychiatric disorders, including anxiety disorders, phobias, and substance abuse disorders.  


If someone had a bad episode of depression that resolved years ago, are they mentally ill?  What if they remain well for years but only if they stay on medication? How sick do you have to be and for how long to enter the club? 


The NAMI website says:
Mental illnesses are medical conditions that disrupt a person's thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life.

Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD) and borderline personality disorder. The good news about mental illness is that recovery is possible. 

I'm not so sure that does it for me.  I'll let you chime in.

Things I'm Thinking About This Holiday Weekend

Happy Presidents' Day.  I probably have 50 blog posts floating around in my head, but I thought I'd share with you some of the stuff I've been reading on line lately.  


The New York Times Op Ed editor doesn't seem to like stimulants these days.   A few weeks back there was an article talking about a study showing that long-term stimulants aren't helpful, and today there is a piece by a writer who finds distraction helpful...told with some contempt towards his friend's son whom he calls Ritalin Boy.  Steve over on Thought Broadcast has his own take on ADD meds.   
 What do you think: are stimulants helpful or not?  I'll stand aside for this one. 


Then there was the article about the business/computer whiz who put hundreds of thousands of dollars of his own money (and all his time) into a kidney transplant matchmaking service.  If you need an uplifting story, this is an interesting one. 


Over on KevinMD,  Dr. George Lundberg is a bit skeptical of SAMHSA's new defining features for the Recovery Movement.  I more or less agree, it feels like it's more about semantics (what does it mean to say recovery is "person-driven"? as opposed to?) than substance, and a lot of it seems to boil down to the idea that patients should be treated with respect and people with mental illnesses should work towards achieving their full potential.  Those things I agree with, for everyone. 


And finally, for the writers among us, Pete Earley has a Before You Quit Your Day Job post up on his blog.  I'm still pondering the $80,000 advance.  The Shrink Rappers need an agent, oh, but we do love our friends over at Johns Hopkins University Press.  


And finally, for my friend ClinkShrink the Introvert,  who wrote a review of a Quiet: The Power of Introverts in a World that Can't stop Talking (---huh, stop looking at me), here is an article called The Brainstorming Myth by Jonah Lehrer in The New Yorker. 


Okay, lots of links.  This is what I've been thinking about.  Aside from that, I made a quick trip to NYC and had my photo taken with Cookie Monster in Times Square, and I loved Jersey Boys.

The Opinionater on The Age of Anxiety

Before I start, two things: 1) if you'd like to hear our interview with Dan Rodricks on WYPR today, go here.  2) If you've ever been forcibly certified to a psychiatric unit and you haven't taken our poll yet, please do so here.  And now for our next post:
 
Over on the New York Times "Opinionator," Daniel Smith has an article called ""It's Still the Age of Anxiety.  Or is it?"  Smith talks about W.H. Auden's Pulitzer Prize winning1948  poem, The Age of Anxiety, (it's boring, he tells us, as well as 'illusive, allegorical and at times surreal') and he tells us about his own anxiety.   Smith writes,


From a sufferer’s perspective, anxiety is always and absolutely personal. It is an experience: a coloration in the way one thinks, feels and acts. It is a petty monster able to work such humdrum tricks as paralyzing you over your salad, convincing you that a choice between blue cheese and vinaigrette is as dire as that between life and death. When you are on intimate terms with something so monumentally subjective, it is hard to think in terms of epochs.

And yet it is undeniable that ours is an age in which an enormous and growing number of people suffer from anxiety. According to the National Institute of Mental Health, anxiety disorders now affect 18 percent of the adult population of the United States, or about 40 million people. By comparison, mood disorders — depression and bipolar illness, primarily — affect 9.5 percent. That makes anxiety the most common psychiatric complaint by a wide margin, and one for which we are increasingly well-medicated. Last spring, the drug research firm IMS Health released its annual report on pharmaceutical use in the United States. The anti-anxiety drug alprazolam — better known by its brand name, Xanax — was the top psychiatric drug on the list, clocking in at 46.3 million prescriptions in 2010.

Just because our anxiety is heavily diagnosed and medicated, however, doesn’t mean that we are more anxious than our forebears. It might simply mean that we are better treated — that we are, as individuals and a culture, more cognizant of the mind’s tendency to spin out of control.

Smith concludes that it's not the world we live in, and that it's perhaps dangerous to make that assumption.  He notes, " If you start to believe that anxiety is a foregone conclusion — if you start to believe the hype about the times we live in — then you risk surrendering the battle before it’s begun."

What do you think?  Are we more anxious than we used to be?  And why is that?  Is it the world we live in--now or in 1948?  Or is it just our own personal psyches?   

Note, the graphic above is from a book by Andrea Tome. 

Podcast #62: Sooner Rather than Later

We talk about the following topics:

• Roy asks listeners to suggest a topic for our next book (Dinah and Clink suppressed all urges to scream).

• Professionalism and social media for physicians.  Roy refers to a post he wrote and Mark Ryan's discussion of the challenges of determining what is professional in social media. We ramble a lot and Dinah talks to much.  Here is the AMA policy on Social Media.  Should psychiatrists put their poetry and their political beliefs up on the internet? We don't talk about Google+ now, but we do talk about not talking about Google+ now.

• Clink and Dinah argue about whether we (the Shrink Rappers) know a lot about social media.

• We discussed how Dinah isn't sure she believes that psychiatric patients die an average of 25 years before people without mental disorders.  Roy referred us to this article on life expectancy in chronic mental illness.  Is earlier mortality due to antipsychotic use?  Is it due to lack of coordination of medical care?  ClinkShrink tells us that people with personality disorders die more of all causes and we talk about who the studies address.

• We finally discussed Google plus-- is it going to add to medical social media or is a party that no one is going to?  Roy likes it better than Facebook & Twitter and he invites you to join his Shrink Rap readers' circle.  ClinkShrink predicts that social media will die and Roy disagrees.  He talks about the PatientsLikeMe website and an article on How Google+ Could Transform Healthcare.  

• We digress to topics of electronic medical records and what to do if patients don't want to know their diagnoses or do want to see their medical records.  I do believe we could talk about this subject for all eternity.  We came close.

No clue why ClinkShrink titled this "Sooner Rather than Later."


This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post

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Guest Blogger Dr. Andrew Angelino on AIDS, Russia, and Collaboration in Medicine

Every month, the president of our state psychiatric society writes a column for the newsletter.  This month, I read it and thought the column, directed only at psychiatrists, would make a good Shrink Rap post.  Dr. Angelino has graciously allowed us to reprint his article:

“I’d like to talk to you about this patient….”

Some presidents follow a format for these columns.  I have nothing against formats except that I hate them for their…well, “formatness.”  The way I see it, I get to write to you all about 10 times this year and they’ll print what I write pretty much for free and without question, as long as I make some degree of sense and don’t embarrass myself or the profession too much.  So, what I’m really trying to say here is, I hope you enjoy what I have to say. I hope it makes you think a little, and more importantly, I hope it makes you want to talk to another psychiatrist a little, because that’s my goal as your president – to get you involved in the conversation.

I just got back from Russia.  I spend about a week or two a year teaching AIDS Psychiatry in various cities in Russia.  Nowhere glamorous.  Usually, I get to go deep into Siberia in the middle of winter and freeze off body parts.  Although, there is something to be said for opening a conversation with “The last time I was in a Siberian prison….” 

AIDS Psychiatry is an interesting little niche.  Basically, I see patients with HIV infection who have mental health problems.  For the most part, people think that the role of the psychiatrist in this area is mostly dealing with grief or other adjustment issues – basically talking to folks about their concerns over having a life-threatening infection.  Slightly more sophisticated, some recognize that the action of HIV in the brain causes mental problems – dementia and major depression are examples.  But what many don’t think about is that HIV infection is an outcome of mental illness.  That the reason we have such a high concentration of individuals with mental illnesses in HIV clinics is that their mental illnesses render them vulnerable to behaviors that lead to outcomes like HIV, hepatitis, imprisonment, homelessness and other disenfranchisements.  And once they’re infected with HIV, we have complex mentally ill patients that now have to try to manage a life threatening infection along with their mental illnesses.  Basically, that’s my job: help the most vulnerable manage an incredibly difficult task, for the rest of their lives.

Now I’m not telling you this to toot my own horn.  I’m telling you because I learned, from a whole lot of firsthand experience, that all this integrated healthcare, medical home, accountable care mumbo-jumbo really works.

In my clinic, the psychiatrists work in rooms next to the medical doctors.  Today in clinic, I spoke to Mark Sulkowski, infectious diseases doc specializing in HIV-hepatitis C coinfection.  We have several patients together.  I know I can knock on his door anytime he’s not with a patient to discuss a patient or the latest new drug for hepatitis C (we have two new protease inhibitors that will likely increase cure rates).  We also have social workers and pharmacists and case managers and primary care docs and OB/GYNs and dermatologists and ophthalmologists and neurologists.  And we all write in the same charts and manage the same patients together.

In Russia, no such system exists.   Last week, we were discussing the tricky problem of managing patients with HIV infection, active tuberculosis, and active injection drug use.  The biggest problem is there is no system.  TB is treated in the TB clinic, HIV in the HIV clinic, and drugs in the “narcology” clinic (which is independent of both psychiatry and general medicine).  And nobody talks to anybody else.  The Russians are fascinated by the stories of how my clinic, and other HIV clinics in the US with some of the same services, manage complex patient issues.  They are in awe of the resources we can bring to bear to overcome a problem like adherence to medications.  And they are also in awe of our commitment to the public health that permits us to take a stand like mandatory TB treatment using directly observed therapy.

At the MPS annual meeting, I made a short speech.  I said I wasn’t going to stand up to say we have a broken health care system because I didn’t believe it, and I still don’t.  I think we have great health care in the US – it’s just not universally very focused.  We’ve let freedom to choose (a really good thing) gum up a system that can, and sometimes does, work wonders. 

And our profession has taken that a step farther.   We’ve lost ourselves a little in psychiatry and forgotten what makes us most useful to our medical family – our ability to influence attitudes and behavior.  We’ve occasionally let our patients excuse behaviors with mental symptoms and allowed them to fail because we sometimes overvalue their free will to choose to ruin themselves. 

We face issues in the approaching health care “reform.”  The same kinds of issues Russia is facing.  Do we remain in silos and let patients fail because they don’t integrate for us, or do we step into each other’s spaces and learn to co-manage difficult cases?  Do we let payors divide us and limit our work together, or do we strive to demonstrate how effectiveness in one compartment can have benefits in another, thus balancing out for the “whole patient?”  Do we become so specialized in our area that others with no medical training threaten to replace us because they are willing to work cheaper, or do we demonstrate the enhancement medical training has on our ability to integrate with our medical colleagues?

Every time we pick up the phone to talk to the patient’s primary care physician, we integrate health care a little more.  Every time we fax over a note, or send a short (encrypted) email, we integrate a little more.  Shared access to an electronic medical record between Emergency Department doc and psychiatrist?  You bet that’s integration.  And you’re already doing it all the time, I know.  So this “reform” should be a breeze, right?    I guess that’s why I can spend some of my time working on the Russian problem.

Understanding the Research on Psychotherapy Trends-- a Discussion with Dr. Ramin Mojtabai

For whatever reason, it bothers me when media says that psychiatrists don't do psychotherapy, and lately, it happens a lot.  What am I, chopped liver?
They quote a study by Mojtabai and Olfson in the Archives of General Psychiatry, and say, "Only 10.8% of psychiatrists see all of their patients for psychotherapy."  Is that really true?  Is it really relevant?  I tried to read the article and I wanted to understand how the study was done so I could think about it myself, but I didn't understand how the research was done-- Roy thought it was based on CPT codes, then he said it wasn't.  So why not go to the source?  I asked Dr. Mojtabai if he would have lunch with me and tell me how the study was conducted.

If that got you curious, please read about it on over on Shrink Rap News!  You're welcome to comment there if you're physician, or to surf back here and tell us what you think.  Ramin says he's interested in what people think, and he's been very kind about humoring me, both over lunch and in the many subsequent emails over the details.

Weiner Diagnosis?

 

In Shrink Rapper world, we get a lot of email from publicists about books, TV spots, upcoming events.  This was in my spam box today:

Rep Anthony Weiner is expected to resign today after weeks of scandal surrounding his lewd text messages, tweets and photos.  Even in his tearful media conference, Weiner could not explain why he participated in such behavior.  According to NYU Medical Professor and Internist, Dr. Marc Siegel, the congressman’s behavior is systemic of a larger psychological problem, which must be addressed before fixing the addiction to online sexual activities.  

 

Dr. Siegel says, “This seems to be an example of extreme narcissism, inflated self image, depersonalization, loss of contact with reality, addiction, and the power of the Internet as a medium (like the Wizard of Oz you feel you are hiding behind the curtain)”.

 

To discuss the dangers of addiction and steps to overcome the serious illness, Dr. Siegel is available to offer is medical knowledge.  As a medical practitioner and FOX’s House Doctor, Dr. Siegel has spent years diagnosing and treating people in the national media spotlight.

 

If you are interested in speaking with Dr. Siegel, please contact me at .

 

Best,

Rena  

 

Rena Resnick

5W Public Relations

Oh my, I thought.  I read it twice. An internist is going to comment on Anthony Weiner's narcissism, motivations, sense of self, and contact with reality?   Sounds like a shrinky thing to me, but the Goldwater Rule prohibits psychiatrists from commenting on the mental state and diagnosis of someone they haven't personally examined.  Does that mean it's okay for other specialists to talk about the mental state of someone they don't know?  Hmmm...   I guess we'll see what he has to say, but I'm not so sure about this.

Talk Doesn't Come Cheap

Gardiner Harris has an article in today's New York Times called "Talk Doesn't Pay So Psychiatrists Turn to Drug Therapy." The article is a twist on an old Shrink Rap topic--Why your Shrink Doesn't Take Your Insurance. Only in this article, the shrink does take your insurance, he just doesn't talk to you.

With his life and second marriage falling apart, the man said he needed help. But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Ah, Dr. Levin sees 40 patients a day. And the doc is 68 years old. This guy is amazing, there is no way I could see 40 patients a day for even one day. He's worried about his retirement, but I wouldn't make it to retirement at that pace. Should we take a bet on whether Dr. Levin has a blog?

So the article has a whimsical, oh-but-for-the-good-old-days tone. In-and-out psychiatry based on prescribing medications for psychiatric disorders is bad, but the article doesn't say why. In the vignettes, the patients get better and they like the psychiatrist. Maybe medications work and psychotherapy was over-emphasized in the days of old? The patients don't complain of being short-changed, and if Dr. Levin can get 40 patients a day better for ---your guess is as good as mine, but let's say-- $60 a pop and they only have to come every one to three months, and there's a shortage of psychiatrists, then what's the problem? Why in the world would anyone pay to have regular psychotherapy sessions with the likes of someone like me?

After my post last week about The Patient Who Didn't Like the Doc. On Line , I'm a bit skeptical about on-line reviews. Still, I Googled the psychiatrist in the story, and the on-line reviews are not as uniformly positive as those given by the patients who spoke to Mr. Harris. Some were scathing, and they complained about how little time he spends with them. In all fairness, others were glowing.

The article makes psychiatrists sound like money-hungry, unfeeling, uncaring, sociopaths. Either they're charging $600 a session (...oh, can I have that job?) or the financial aspect is so important that they're completely compromising their values for the sake of a buck. This doctor believes that patients get the best care when they receive psychotherapy, and the rendition Mr. Harris gives is that it's understandable that he's compromised his values to maintain a certain income. I don't buy it and I don't think it portrays psychiatrists accurately or favorably. If the doctor felt that it was the high ground to give treatment to 40 patients a day who otherwise couldn't get care, then this portrayal wouldn't be so bad. And that may be the case---I don't know him and I don't know Mr. Harris and I do know that an occasional reporter has been known to slant a story. I found it odd that there were no other options here aside from 4 patients/hour, 10 hours/day, not to mention the 20 emergency phone calls a day that he manages in the midst of all the chaos. Why hasn't this doctor left the insurance networks and gone to a fee-for-service model with a low volume practice if psychotherapy is what he enjoys and what he feels is best? Or why doesn't he devote an hour or two a day to psychotherapy? Okay, I shouldn't rag on the poor doc, I only know him through a newspaper portrayal, but I don't think this article showed psychiatry at its finest hour. And yes, I know there are psychiatrists out there who have very high volume practices.

It's a Girl!

I'm on a New York Times streak....

In yesterday's paper, Jenny Norberg writes about families in Afghanistan who choose to raise their daughters as boys. Mostly, they do this because it erases the shame the family feels for not having a son, but it also gives the child and the family more freedom (you can't send a daughter to the store for a loaf of bread...do they have loafs of bread in Afghanistan?) and the child gets more educational and occupational options. Read Afghan Boys are Prized, So Girls Live the Part.

The cultural issues are fascinating, but that's not why this article caught my attention. In psychiatry we deal with issues of gender identity and we haven't fully figured out how much of gender identity is determined by unknown genetic influences versus cultural influences versus other factors-- intrauterine exposures, viruses, you name it: we don't know. It was interesting to read the article and read that some girls remained comfortable in the male role-- their 'conversion' to their biological gender with puberty, often heralded with an arranged marriage, was confusing and uncomfortable. One of the women continued to wear pants in private, while another girl was uncomfortable with the male role and wanted to be live as a girl, even though boyhood gave her more freedoms. I wondered, too, how much of the gender switching was random selection---did parents sense that a girl might blend into male life more easily and so pick her, rather than one of her sisters, to live a switched childhood? Does seem like this would make for some wonderful research into gender identity....

Emotion versus Mental Illness

My favorite commenter, "Anonymous," wrote in to my Duckiness post to say that it was good I could post something totally silly without being told I need more meds. Oh, if life were that simple. And it is true that once someone has a diagnosis of bipolar disorder, not only does the world question their emotions in a black & white "are you sick again?" kind of way, but patients don't trust themselves to feel for it's own sake.

If you're not sick, then being asked if you took your meds is insulting and degrading. And so I thought I'd put together some guidelines for Emotion versus Mental Illness. I'm inventing this as I go, with no evidence-based anything, so take my suggestions at your own risk.

• If you are ultra-successful, rich, brilliant, gorgeous, famous, and comfortable with your diagnosis, you may want to consider telling people you have a mental illness because it decreases stigma and people like being with the ultra-successful rich, famous, brilliant and gorgeous and won't care that you have a mental disorder. It helps even more if you're charming.

• If you're not ultra-successful, you may want to pick and choose who you tell that you've been ill and are on medications. This isn't always possible, especially if your illness is evident to others or if the presentation of your symptoms resulted in a hospitalization. It's good to tell close family members.

• If multiple people are looking at you strangely, or commenting on your behavior, or saying you need medications, you might want to at least entertain the option that you could be sick. Unfortunately, poor insight and judgment are symptoms of mania.

• Tell the people close to you not to make medication jokes. It confuses the issue if you seriously do need medication changes, and it's rude, degrading, dismissive, and disrespectful. There, I said it.

• If you want to be silly, go for it. Be silly when you're well so that being silly is part of your baseline personality and no one equates this with being out-of-character. You'll note the duck invaders did not come after me, rather they said, "There's Dinah posting yet another stupid duck post." If I'd posted about why chocolate should be outlawed and made into a controlled substance, those same duck invaders would be asking "What's wrong with Dinah?"

• Mental illnesses come as constellations of symptoms. There is no "Sending out silly duck stuff" as a symptom. People think about mania when the ducks are combined with more energy, racing thoughts, a decreased need for sleep, increased mood OR irritability, and other symptoms of mania. Know the list and if someone bothers you, say, "I posted about ducks, I do not have any other associated symptoms." Recite them if necessary. If you do have the other symptoms, refrain from posting about ducks. I don't want Posts Duck Blog Posts to show up anywhere in DSM-V and these days you just never know.

• No one controls how any other person thinks of them or judges them and it's not reasonable to live life ruled by a desire to be perceived in a certain way . It's another form of poultry, but Don't Let the Turkeys Get You Down. There are a lot of turkeys out there.

Moods happen on a spectrum. Some people have large variations in their mood---large enough or severe enough such that it causes suffering, and we call it an illness. Some people don't have much variety to their moods and live in a calm, even-keel place, and it's great that we have such people. But, I absolutely promise you that if we lived in a world where everyone had a very narrow range of mood, this would be one terribly boring planet. We should celebrate our diversity, not condemn those who like ducky stuff.

Is Your Job a Downer?

1. 

Katina writes to us from onlinecolleges to let us know about a post on which jobs are the top ten most depressing:

Check it out here: 10 Professions with the highest levels of depression.

What I found to be interesting is that the assumption is that the jobs cause the depression.
For example:

1. Social Workers: If you had to deal with abused children, unkind foster parents and less than stellar family dynamics all day, you might be depressed too. Those working in this field are three times more likely to be depressed than the general population, and many are so focused on helping others they don't get the help that they need themselves.

There's nothing in the post that addresses the chicken-or-egg? question. Maybe people with depression are drawn to certain fields. Artists are listed, with the statement that those who chose to work in the field "found it depressing." And everyone kind of gets it: doctors, nurses, social workers, lawyers, artists, janitors, food service people, finance, nursing home and childcare workers. What's left? What's the depression rate among bloggers?

The Guilty Doctor

Times are tight and we're all looking to save money, be it our own or someone else's. Many will say that when it comes to the skyrocketing costs of health care, doctors are responsible for part of the problem. We order too many tests, either to cover ourselves in the event of a malpractice suit, or because patients pressure us, or because we genuinely believe that the tests are necessary for patient care, but in many circumstances, a cheaper option is available. We order medications that are expensive when cheaper medications are available. And psychiatrists offer care-- like psychotherapy-- that could be done by clinicians who are cheaper to educate and willing to work for less money.

Here are some voices on decreasing cost: From KevinMD's post on when patients (in this case the patient is a doctor), pay cash. More on the same story directly from Jay Parkinson, here is Today I Was a Patient. The most absolutely cool thing I learned from Dr. Parkinson this morning is about a website I had never heard of before called ZocDoc which lets people schedule on-line appointments with new physicians (including shrinks!)--like OpenTable for Docs...I asked for more info about this, but such a website fits Roy's vision of dying and going straight to heaven. And MovieDoc has strong opinions on allocating resources: we shrinks should not be letting patients ramble on about their romantic lives, why one psychiatrist can treat 1,000 patients if they stop that psychotherapy nonsense! ClinkShrink, too, has had a lot to say about allocation of services, but I'll stop now before the blog explodes.

I buy it, too. Docs should feel an obligation to care about cost-containment. In recent times, this translates very simply into the fact that I feel guilty no matter what I do. I sit with a patient and I consider trying a cheaper option for medications before I try a more expensive one. But then I think: isn't my obligation to do my very best by this patient? Why shouldn't my patients get the latest-greatest available medication when other patients do? And what's the cut-off for how much it's worth for....relief from voices, a better mood, a good night's sleep? How do we even begin to put dollar signs on such things?

I'll give you a scenario. A patient comes to me already on an anti-psychotic medication. He says it helps, but it's unclear why it was ever started. At some point, he stops taking it, and it becomes much more clear why he ever needed it: he becomes flagrantly psychotic and completely unable to function. I restart the medication, using the one he was on, which happens to be fairly cheap as the second generation anti-psychotics go. So all good: the med works, I know he tolerates it, and it's the cheapest of the choices, by a lot. Oh, until he gains 20 pounds. Now what? There's Abilify which is, oh, many times more expensive, but is less associated with weight gain...should I try that? I hesitate because of the cost, and then I think perhaps I should try one of the older medicines, of the Haldol generation-- much, much cheaper, but many patients hate it. As a field, we seem to agree that these first-generation anti-psychotics are not the way to start; the atypicals are the usual first-line treatment. Maybe this patient won't have side effects, maybe he'll be fine, I could "try." But isn't that making my patient into a guinea pig? If it were me, would I want to try a medication with many known side effects, when other medications are available? Nope. So I go back and forth between what is best for my patient and what makes sense for society. I share some of my thoughts with the patient, whose private health insurance pays for them, and he clearly wants what's best for him, not what saves society money.

I suppose the question presumes that I know what's best for him. And clearly, I don't. One of my big concerns is that he had this awful recurrence of a terrible illness, and each time, it takes weeks to get better,time lost from his life. There is no guarantee that Abilify, with a more favorable side effect profile, will be equally efficacious, or that Haldol, cheaper if you will, will also work. There is the risk of relapse with any medication change and this is why some patients tolerate medications that cause weight gain or diabetes.

And then there is the "at what cost?" for that particular symptom. A patient wants a medication for sleep-- trazodone and benedryl don't work, ClinkShrink flips when anyone prescribes Seroquel for sleep ($3/pill for 25 mg per drugstore.com), benzodiezepines are contraindicated, and then there's Rozerem at $5/pill. Is a good night's sleep worth $5 night? Of whose money? And what if the patient is on generic Ambien ($1/pill or less) but wants to take Ambien CR ($4/pill) because it helps him sleep longer? And how do you feel about Provigil, which comes in at $20 a pill for the 200mg dose? Stepwise therapy, you say--- where a patient must try cheaper medications before he is allowed access to the more expensive ones? And who determines efficacy? And how do we deal with the hassles of pre-authorization? Maybe we should decide that certain medicines are so expensive that they shouldn't be offered to anyone?

Charlie Rose: The Brain Series: Mental Health

In case you missed it, Charlie Rose had quite the guest list this week in Episode 9 of his Brain Series:

Helen Mayberg , Jeffrey Lieberman, Kay Redfield Jamison, Eric Kandel, Stephen Warren and Elyn Saks in Science & Health on Thursday, July 8, 2010

Here is a link with the transcript of the interviews: http://www.charlierose.com/view/interview/11113#frame_top

Nobel Prize winner Dr. Eric R. Kandel co-hosts the show with Charlie Rose, and to quote Dr. Kandel from the transcript:

The whole history of psychiatry, which is a culmination of Emile
Kraepelin, is interesting.  We’ve known about these illnesses since
Hippocrates, the great Greek physician in the 5th century, who not
only spoke about depression and manic-depressive psychosis but
specifically indicated that these are medical illnesses.

But this basic idea was lost on European medicine for the
longest period of time.  During the middle ages, even later in
the Renaissance period, these were thought as demonic disorders,
people possessed by the devil or moral degeneracy.

And people with mental disorders were put away in insane
asylums usually far removed from the center of town and often
they were kept in chains so they don’t move around.

Fortunately, this situation was reversed in about 1800.  The
Paris school of medicine began to really express a very modern
view of medical science.  And Philippe Pinel, a great French
psychiatrist, realized psychiatric disorders, as Hippocrates had
said, are medical illnesses, and he began to institute humane
treatment, the beginning of psychotherapy with mental patients.

But from 1800 to about 1900, no progress was made in
understanding psychiatric disorders.  One couldn’t localize
them specifically so one didn’t know is there one mental illness
or are there many?

And that’s when our mutual hero, Emile Kraepelin, came on the
scene. And his textbooks which began to emerge around 1902 and
continued until he died in 1926, he outlines, for example, in this
book in his first three chapters he defines the fact that mental
illnesses are not unitary.  They affect two different processes,
they affect mood, emotion on the one hand, and affect thinking on
the other.

And he defined the disorders that affect mood -- depression and
manic-depressive disorder, and he defined the disorders of thinking
as schizophrenia.  He called it dementia praecox.  He thought it
was a deterioration of cognitive process in the brain early in life,
praecox.

And as you outlined, we have some insight into the nature of
these diseases.  We know that depression is an illness that involves
mood, which is associated with the feeling of worthlessness, an
inability to enjoy life.  Nothing, it’s all pervasive -- nothing
gives one pleasure.

And there’s a feeling of helplessness, of worthlessness, often
leading to thoughts of suicide and, tragically, to suicide attempts
themselves.

And 25 percent of people that have depression also have manic-
depressive illness.  They have the opposite end of the spectrum.
They feel fantastic at the beginning of the disease.  They feel
better than they’ve ever felt in their life.  But ultimately this
leads to grandiosity and frank psychotic episodes.

Schizophrenia is a thought disorder that has three types of
symptoms-- positive, negative, and cognitive.  The positive symptoms
are characteristic I can of schizophrenia.  It’s the thought disorder,
hallucinations, delusions, the acting crazy.  The negative symptoms
are the social withdrawal, the lack of motivation.  And the cognitive
disorders are the difficulty with organizing one’s life and a
difficulty with a certain kind of memory, called working memory,
short-term memory.

Fortunately, as you indicated, we can now see people who have had
effective treatment who have very productive lives.  And Kay Jamison
and Elyn Saks, despite the fact they suffered the this disorder much
of their life, have rich personal lives, both of them involved in
meaningful interpersonal relationships, marriage, that is very
satisfying to them and having spectacular academic careers.

So there’s tremendous hope for the treatment of the disease.

I'm Still Here.

I'm talked out on the subject of whether or not psychiatric illnesses exist and whether or not psychiatric treatments work. I went to work today. I think I'll go again.
For the sake of completion, here's Louis Menand writing in The New Yorker, "Head Case." Click the link and read away.

Why Can't We Be Sad?

Today's New York Times Magazine has a really interesting article by Jonah Lehrer called "Depression's Upside." Mr. Lehrer talks about a possible evolutionary purpose for Major Depression.

Mr. Lehrer writes:

The persistence of this affliction — and the fact that it seemed to be heritable — posed a serious challenge to Darwin’s new evolutionary theory. If depression was a disorder, then evolution had made a tragic mistake, allowing an illness that impedes reproduction — it leads people to stop having sex and consider suicide — to spread throughout the population. For some unknown reason, the modern human mind is tilted toward sadness and, as we’ve now come to think, needs drugs to rescue itself.

The alternative, of course, is that depression has a secret purpose and our medical interventions are making a bad situation even worse. Like a fever that helps the immune system fight off infection — increased body temperature sends white blood cells into overdrive — depression might be an unpleasant yet adaptive response to affliction. Maybe Darwin was right. We suffer — we suffer terribly — but we don’t suffer in vain.

So I didn't like the article at the beginning; it relied on anecdotes--the woman who felt so much better with antidepressants that she'd grown complacent in a bad marriage, for example. It doesn't capture all the patients I see, and any way you dice it, if you end up dead from suicide, your productivity comes to a halt. It seems to me that there are some people who suffer in ways that these anecdotes don't explain. I suppose, however, even if we assume that depression is an unproductive, tormenting state, when it ends, is there something to be gained from having gone through it. Lehrer tells us, "Wisdom isn't cheap, and we pay for it with pain." I, personally, think there remains a differentiation between pain and major depression, and that perhaps one can grow through all sorts of suffering, and I'm all in favor of finding my own personal path to wisdom in ways that might not entail so much suffering. Just a thought.

But I ultimately, I liked the article because Lehrer, while clearly a proponent of the "don't mess with evolution, less drugs, please," school of thought, presents a balanced view. He gives Peter Kramer (Listening to Prozac) a voice, and talks about the objections to the viewpoint he puts forth. He describes a theory that depression is evolutionarily helpful because of the ruminative nature of the illness. He also cues us in that this is just one explanatory theory which remains unproven, and there are others. Lehrer continues:

Other scientists, including Randolph Nesse at the University of Michigan, say that complex psychiatric disorders like depression rarely have simple evolutionary explanations. In fact, the analytic-rumination hypothesis is merely the latest attempt to explain the prevalence of depression. There is, for example, the “plea for help” theory, which suggests that depression is a way of eliciting assistance from loved ones. There’s also the “signal of defeat” hypothesis, which argues that feelings of despair after a loss in social status help prevent unnecessary attacks; we’re too busy sulking to fight back. And then there’s “depressive realism”: several studies have found that people with depression have a more accurate view of reality and are better at predicting future outcomes. While each of these speculations has scientific support, none are sufficient to explain an illness that afflicts so many people. The moral, Nesse says, is that sadness, like happiness, has many functions.

The article finishes off with the idea that people in depressive states are better thinkers, they notice more, they work better. He talks about a study that shows that on gloomy days with dismal music playing, shoppers notice more trinkets by the cash register. Gloomy weather and oppressive music might set a low mood tone, but this seems a far cry from an episode of major depression, and not something that is generalizable to anything more than clouds and music and trinkets. There's a second study mentioned of undergrads doing an abstract reasoning test that shows people with a "negative mood" perform or focus better; again, it falls short of being a comparison for major depression. The shrinks among us find it hard to imagine that 'negative moods' and Major Depression are all that linked. Everyone has negative moods. Not everyone has major depression.

What about the studies that link mood disorders and creative tendencies? This does seem likely, and we're left to wonder (my own thoughts, not the article) if the intense experience of an episode of mood disturbance either fuels creativity by feeding it material or requiring a release, or if the genetics are wired such that mood disorders and artistic talents might be coded near one another.

You thoughts?

What's Holden Got?

There's a copy of the DSM-IV sitting on my coffee table. Not the usual, not even at a Shrink Rapper's house, but I'm trying to write the Shrink Rap book and, in theory, I may need to look something up.

So, kid looks at the DSM and informs me, "We read that in English class today." They read the DSM in English class? Hey in the good old days, we read Macbeth in English class. We didn't need psychiatric diagnostic manuals. "Oh, why?" So they're reading Catcher in the Rye and they decided to diagnose Holden Caufield. Interesting. What's he got? Oh, we shrinks don't do that. Until I personally examine Holden, I'm not venturing a guess as to his psychiatric diagnosis. The APA and the medblogging community would have me de-shrunked.

So what did the English class say? (They're kids, they can venture guesses if they like). One thought he had Borderline Personality Disorder, some thought he had Bipolar Disorder, and a few thought he had Schizophrenia.

Funny, I was writing today about how hard it is to diffentiate developmental issues, family complexities, and psychiatric illness in adolescence. Seems like a funny coincidence.
Well, what's Holden got?

Making Sense of a Senseless World.

You think this post is about psychiatry. Or life in general. Here is going to be the secret, how to unravel it all so it makes sense.

Ha! Tricked you! I just found an article in the New York Times (from 1.15.09) called The Man Who Makes Sense of 'Lost.' It's about Gregg Nations, a man whose job (he gets paid for this!!!) is to keep track of the plot lines for the TV show LOST, a favorite of both Roy and I. This is the thing though, I watched the first season on DVD on vacation, 2-3 episodes a day, it was riveting, no commercials, no waiting a week to see what happens. I watched a couple more seasons on DVD, but not at the same rate, and the plot started to get a bit confusing. Or rather there were too many different plots going on at the same time and more and more plot lines started with more questions being asked but not enough being answered. And I caught up to the real-life show, and now have to watch it on TV, with the week-long breaks between episodes, noise of regular life, and season breaks. The show travels back and forth through time, I never figured out why Benjamin (the bad guy) was shown for a flash as a security screener in the airport in Australia, or what was with the polar bear on the island, and now we travel back and forth in time in vague and mysterious ways. There are puffs of smoke, bodies lost and found, lovers in countries down the road, and an island that splits and has the magic power to heal cancer and paralysis Nothing quite rivals that first season, with the number sequence that had to be typed into the Dharma station machines ever 108 seconds or else...or else what?

So I'm Lost. It was good to read that other people are Lost, and that even the show's script writers have trouble keeping track of the intricate plot. I didn't realize there were over 100 characters. Will they be my Facebook friends?

And Therapy Patient, there had better not be 20 million people headed to Washington on Tuesday. Shrink Rap will be reporting.

Trapped! And Under the Floorboards, at That!

So Clink and I went to see Roy today. He has a big big screen and if you want to do work as a group, it's really helpful. We wanted to review our Table of Contents for our book proposal, to make sure we covered what we want to cover, to make sure we weren't being repetitive. This is an interesting process just writing a proposal with three people. Roy suggested we might need three keyboards and three mice to control the single huge screen. I suggested that if we did that, we'd also need a gun. Things get a little loud. I'm the least detail oriented of the three of us, and I tend to type fast but not quite as fast as I think, so often my stuff is missing a word here or there. What's the biggy? Roy likes the to be perfectly consistent and he worries over every word. Clink, well, she's more of a big picture type of nun, so she sits there in her habit and only gets bloody once in a while.

So Roy is in a hurry, busy man with obligations to be met. Suddenly, he's handing me a key and telling me we can stay as long as we like, but do lock up. He's off. Clink and I remain, clicking away at our document, and at the end, I'm left with Roy's 75 open documents on the screen, layered and overlapping, and never fully closeable, simply trying to log out of my own e-mail account because I don't want a whole gang of people later having a party over the ridiculousness of what goes on in my life.

We're finally done and Clink and I gather up our junk. Bye to doggy. Out we go. Oh, but we can't get out. There are Two locks on the door and we're twisting and turning for a while. Finally Clink says, "When did he say he's coming back?" Uh, he didn't. We try the top lock and then the bottom lock and some random pulls here. I got stuffs to do. Clink says "This is definitely a blog post." This makes it better. Clink always makes it better. I laugh at the thought, and we're both about to turn back to the mega-screen to start blogging away about being trapped and Royless at Roy's, when the last turn of the lock and pull on the door finally frees us.