Capitated care, Young Brains, & Suicide Prevention Police

Thank you to everyone has been participating in our multi-post discussions of Capitated Care versus Fee-for-Service.  Based on the input of our readers,  I've come to the conclusion that in systems with capitated care (i.e., a national health system): 1) Our readers are pleased with that, feel it provides better blanket coverage to a large population and the emphasis is more on medicine and less on money.  2) Capitated care is less about service with a smile.  3) Capitated care does a better job with treating populations but may not be the best care for the individual with an outlier problem.  We've heard about systems in Canada, the UK, and Hong Kong, and of course, the USA.  I can't recall whether our Australian readers chimed in.

In today's New York Times, I wanted to give a shout out to a couple of articles about psychiatry. 

Robert Cantu and Mark Hyman have a book out called Concussions and Our Kids, and Dr. Cantu has an op-ed piece in today's paper, "Preventing Sports Concussions Among Children,"  talking about measures we should take to prevent brain injury during routine team sports for children under age 14.  The bottom line: children should not play tackle football, head the ball during soccer, body-check in hockey,  add chin-straps to batting helmets and eliminate head-first slides in baseball, and require helmets for field hockey and lacrosse players.  As psychiatrists, we're rather fond of intact brains.  The authors challenge us to re-think our approach to children's sports.  

The New York Times also has a nice article on the NYPD's Emergency Service Unit, an elite squad of 300 police heroes who talk people off bridges and rooftops.   So far this year, the NYPD has gotten 519 calls for people who are about to jump.   See Wendy Ruderman's, "The Jumper Squad."

Ducking Around

Ooooh, let me tell you: I love vacation.  I really love vacation.  I'm back.  It's cold here, and I spent the day unpacking and doing laundry, and getting ready to start my week.  I returned calls, went in to the office and checked my mail, emailed, postal mailed, and watched the Ducks win the Rose Bowl.  Sad, because even though we Shrink Rappers like ducks, I have my own personal Badger out in Pasadena cheering for Wisconsin, and it's a sad football day for him, I'm sure. 


Roy did a great job of holding down the blog.  Please give him a hand.  Clink was off on another one of her adventures.  For some reason, vacation is not fun for her if there isn't the possibility that she'll fall thousands of feet, get eaten by some form of wildlife, or have her life depend on properly functioning equipment while she gurgles beneath the sea.  She's the only person I know where "I had a fantastic time" is followed by an injury report.


Roy's Happy New Year duck was taken from the Havre de Grace annual New Year's Duck Drop.  From the Aegis:

It was a glorious night for ringing in a new year. Temperatures, unusually inviting for a New Year's Eve in Harford County, hovered around 43. Wind was non-existent. And many people had gathered around the Havre de Grace Middle School grounds for the annual Duck Drop and fireworks to welcome another new year.

In other stories around the web, if you're a distracted duck, you might have notice that it's hard to find Ritalin or Adderall-- perhaps another example of DEA limits allowing Big Pharma to be being overly ducky about reducing supply of the cheaper, generic medications.  From the The New York Times, do check out "A.D.H.D. Drug Shortage Has Patients Scrambling."  


And if you're a duck contemplating filing for Social Security Disability, do read Dr. Steve's post on Thought Broadcast about The Curious Psychology of "Disability."  With 41 comments on that post, I'm going to swim away from the temptation to comment myself. 

And finally, for those ducks who want to know the latest on Electronic Medical Records, check out Shrink Rap News over on CPN for "Notes from SAMHSA's EHR Summit."  If that doesn't make you want to be served up with orange sauce, then nothing will.

So I love vacation, but I did miss all the Shrink Rappin.'  Happy New Year to everyone!  

From Clink: I don't have a duck in this race, so I thought folks might enjoy a seahorse instead. He's black with white stripes and seems to be perched on top of the green moray eel's head. Yes, the eel was that close.

No significant injuries this time.  A slight jellyfish sting and lots of no-see-'ums, that's it.

Suicide, Brains, and Football

In yesterday's New York Times, Alan Schwarz wrote about the tragic suicide of football player Dave Duerson this past week. Schwarz notes that prior to shooting himself, Duerson texted family members that he wanted his brain examined for Chronic Traumatic Encephalopathy, a condition we've discussed before in our post Brains, Behavior, and Football.

Schwarz writes:

Doctors, N.F.L. officials and even many players denied or discredited the links between football and such brain damage for months or even years. The roughly 20 cases of C.T.E. that have been identified by groups at Boston University and West Virginia University were almost always men who had died — most with significant emotional or cognitive problems — with no knowledge of the disease. Now, for the first time he knows of, Stern said, a former player has killed himself with the specific request that his brain be examined.

I'm left to wonder, did this former football player have this problem? Sometimes depression alone causes memory problems and sometimes people with depression worry that they have Alzheimer's disease, or any number of other illnesses for that matter. Treating the depression may help the memory problems, and may alleviate the fears of other illnesses. And we don't know much about the Chronic Traumatic Encephelopathy induced by repeated head injuries: is the course of the dementia altered by early intervention with medications? Does the depression respond to the usual treatments for mood disorders? Could Mr. Duerson have been saved, at least for a while?

Here's an article on the treatment of chronic brain injury with hyperbaric oxygen in animal models:
http://www.hbot.com/first-successful-treatment-of-chronic-traumatic-brain-injury

And here's an emedicine article on treatments for repetitive brain injuries (not necessarily specific to CTE) with medicine recommendations, but no mention of antidepressants or medicines to slow the course of dementia:
http://emedicine.medscape.com/article/92189-treatment

Here's a medscape article on CTE and dementia:
http://www.alzheimersreadingroom.com/2010/08/causes-of-dementia-chronic-traumatic.html

And, finally, here's a shout out to my friend and med school classmate Robert Morrison, M.D., Ph.D. whose paper for our public health class was published in JAMA back in 1986 as a state of the art review of boxing and brain injury: http://jama.ama-assn.org/content/255/18/2475.short

Is it worth it in the name of sports?

Could I ask a huge favor of the next football player who considers suicide? Instead of completing the act, could you have your depression treated and then write about the results? It would be an enormous contribution. Sure, it would be an anecdote, and not a controlled trial, but perhaps it would add something to the field. And we'd be happy to publish your story here on Shrink Rap.

My heart goes out to the family of Dave Duerson.

Super Bowl Psychiatry

Enough meditation. Let's move on to what people really talk about in psychotherapy: Football.

And no, I'm not kidding.

Here in Baltimore, the hype's died down as the fans remain catatonic. The purple lights have fadded and the only energy left is that which remains to cheer against the Steelers. Oh, something tells me that on Sunday, there will be lots of energy for Steeler hatred.

I don't really get it-- it's a bunch of too-big, way-too-old, guys in silly outfits chasing balls and charging at each other and they get paid millions to do this. I suppose it's an escapist thing, but I've learned never to say aloud that I don't get it, or worse, that it's just a game.

So SuperBowl Sunday, and the fans are psychiatric patients waiting to happen....the beer and the beer and the beer and maybe the fights will break out and they'll all end up on line to see ClinkShrink. Oh, and the angst and the panic, and the pre-game anxiety and the post-game euphoria/depression.

New York Times report Benedict Carey talks about treatment options in A Home Treatment Kit for Super Bowl Suffering. Mr. Carey suggests:

Breathing exercises are highly recommended and become increasingly important as the football contest nears the fourth quarter, when events on the field are likely to prompt strong physiological reactions, like a pounding heart, hyperventilation, even dizziness. These internal cues, as they’re called, can escalate the feeling of panic, a self-reinforcing cycle resulting in groans and cries that can be frightening to small children, pets and sometimes neighbors.

In the final minutes of the game, be forewarned: Many patients will move beyond the reach of therapy. Their faces may change, their breathing appear to stop. Researchers have not determined whether this state is closer to Buddhist meditation or to the experience of freefall from an airplane. All that is known is that, once in it, patients will fall back on primal coping methods, behaviors learned in childhood within the cultural context of their family.

Like emitting screams. Or leaping in an animated way, as if the floor were on fire. Or falling on their back and moving their arms and legs like an overturned beetle, in celebratory fashion.

This post is dedicated to my husband and son.

Brains, Behavior and Football

In psychiatry, we've had a hard time drawing precise links between brain pathology and psychiatric disorders. We can do it for groups of people: Disease X is associated with changes in brain structure of Brain Area Y or metabolic changes in Brain Area Z. But it's groups, not individuals, and it's an association, not a cause>effect, or a definite. We still can't use this information for diagnosis, and there are still patients with any given psychiatric diagnoses who will have brains where Area Y is the same size as those without the disorder.

We're learning.

From what I read in this New York Times article, Owen Thomas was a bright, talented young man with no history of psychiatric disorder, and no history of known concussion. In April, he committed suicide-- a tragedy beyond words. Sometime people commit suicide and every one is left to wonder: there was no depression, no obvious precipitant, no note left behind, and every one is left to wonder why. The guilt toll on the survivors is enormous, as is the grief for their families and communities. In this case, according to the Philadelphia Inquirer, the young man was apparently struggling with the stress of difficult school work and concerns about his team and employment.

Owen's family donated his brain to Boston University's Center for the Study of Traumatic Encephalopathy.

They discovered that Owen's brain showed damage similar to that seen in older NFL players who've-- he had a condition called Chronic Traumatic Encephalopathy. In terms of Owen's suicide, it's hard to know what this means: did the brain injury contribute to or cause a psychiatric disorder, such as depression, that led to his suicide? Did it make him more impulsive, so that he was more likely to act on suicidal thoughts? It's hard to say: suicide is a common cause of death among young people who die. This is the first documented case of chronic traumatic encephalopathy in a college football player. It's not, however, the first suicide of a college football player.

The only way to know if encephalopathy causes depression which causes suicide, is to keep studying it. It's horrible to lose a child, and I applaud this young man's parents for contributing his brain to a research project, and for making his situation public. Millions of young people play football each year: maybe we need to be doing more to protect their brains, though that will not be popular statement among die-hard football fans (some of whom are my relatives). When it comes to sports and driving, we tend to minimize the risks. On the other hand, it's hard to live life with the shutters drawn.

If you're an athlete, help the cause and donate your brain here.

Ron Artest: Shout Out To The Shrink!

Okay, so my gang wanted the Celtics to win. But then Lakers player Ron Artest thanked the people in his hood, his family, and his psychiatrist! You can watch the video above.



From Puggle:

The famous player of Lakers, Ron Artest thanked his psychiatrist. Ron Artest delivered a surreal interview after winning the seventh game of the ‘National Basketball Association’ finals. He showed his gratitude to his supporters in the interview. After thanking his neighborhood buddies, his family, his wife and his children, he surprised everyone by thanking his doctor and his psychiatrist (a daring confession). Even Dennis Rodman did not dare do such kind of act.

At the final and the most important moments of the game, Kobe Bryant passed the ball to Ron Artest and Artest displayed his career building shot.
After thanking his family, his family friends, his dear ones and his wife and children, Ron Artest stunned everyone by thanking his psychiatrist. In fact, he expressed his thanks twice. He stated that his psychiatrist had a lot to do with his success. He added that his psychiatric consultant helped him a lot in staying calm, relaxed and focused. Furthermore Ron Artest added that his psychiatric analyst cleared his mind and offered him a perspective of lucid ‘Visualization’. The scenario resembled the famous Hollywood flick “The Love Guru” in which the ice hockey player thanked his Guru for his words of wisdom.