Now is the Time: Sebelius, Hyde, and Insel Begin National Dialogue on Mental Illness

HHS Secretary Sebelius held a public phone call on Jan 16 regarding the expansion of mental health (MH) treatment, especially for kids. This was the day after President Obama's "Now is the Time" [pdf] plan was released. The recorded 30-minute phone call is available until Feb 15 and can be listened to by calling 888-568-0013 (no codes or anything).

Here are some of the points I noted while listening:

• 60% of people with mental illness and 85% of people with substance use disorders do not receive help
• failure to receive help is largely due to stigma and people not asking for help [umm, what about failure to access help due to insurance barriers and inadequate and inaccurate provider directories?]
• Project AWARE to train 5000 MH professionals to help identify MH problems in school age kids
• to help eliminate stigma, she will be initiating a year-long "national dialogue" about mental illness, focusing on young people
• mentioned a Healthy Transitions program for young adults

Then SAMHSA Director Pam Hyde entertained questions from callers. My telegraphic notes are below:

• peer specialists (Pam called them "peer professionals")
• surrogate parents and their MH needs
• workforce issues
• correlation of violence w psych meds; toxic practices w/in MH; stigma of coercive treatment; fear guns removed w/o reason 
• veterans' advocate in Michigan: how do we determine who is at risk and who is not; removing vets' guns; how to reach people in gangs
• APRN public health nurse: expanding nurses' scope of practice to treat people with mental illness can improve access
• hope for expansion of voluntary, and not involuntary, treatment; "open dialogue" concept from Finland
• ACLU: training police to deal better w MH symptoms, esp in kids, so they don't enter the justice system
• NFFMH: concerns about cuts to existing programs for families

NIMH Director Tom Insel was also present, and said additional questions and comments can be sent to this email: externalaffairs@hhs.gov.

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 

Blame the DSM?

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


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

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

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

Caplan continues

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


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

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

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


Caplan, a Harvard psychologist, goes on to discuss a complaint she is helping to file against the DSM editors on behalf of 10 patients who were misdiagnosed. "Psychiatric diagnoses," she concludes, "are not scientific and they put people at risk."
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Where do I even begin?  Please, please, I don't know the patient, I only know the presentation given, and I'm going to be very sarcastic, because the way it was presented struck me a ridiculous and it distracted from some valid points that might have been made if there wasn't the Evil, Idiot Psychiatrist Theme with a sensationalist tone.  Shame on the Washington Post for printing this.

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


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


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


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


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


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


Okay, I am ranted out.  

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.

Forced Treatment: Does it Help?

Go for it, I know we have many readers who oppose forced treatment.

  In "Opposing View: Forced Care Doesn't Work"  by Joseph A. Rogers in  USA Today discusses the usefulness of forced treatment.  While some would contend that people who are sick may become dangerous, lack insight, or be so sick they can't see themselves as ill, Rogers contends that by forcing people into treatment, they get turned off on the idea of getting care and that a better solution to the problem is to make psychiatric care something patients want to get.    Rogers writes:

Studies have shown that what works is not force but access to effective services. We don't need to change the laws to make it easier to lock people up; existing laws provide for that when warranted. Instead, we need to create and fund effective community-based mental health services that would make it attractive for people to come in and receive care, and that would support them in their recovery.


I don't know if better access to good care is the whole answer, but it's not a bad place to start.

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Recent posts on forced treatment:
Jan 9: Forced Treatment: Does it Help? ("make psychiatric care something patients want to get")
Jan 13: I'm Sorry ("I'm sorry that... the mental health system has failed [those who have died due to hiding from 'treatment']")
Jan 14: What We Need (list of 12 things readers are saying they need from the MH system)
Jan 14: Poll: Involuntary Commitment: Would you do it again? (a survey for those who have been committed in the past)

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Tell Me.... an Ethical Dilemma

Sam is young man is applying for a summer program, a real resume builder.  Among other things, the application asks if he has been treated for a psychiatric disorder.  In fact, he's seen a therapist and he's felt anxious at times.  His internist gave him some Lexapro samples and he feels better.  The symptoms of his problems have been limited to his own subjective distress.  His anxiety is not something that has disabled him, in fact he has not missed a day of school in 3 years -- and then for the flu-- he sees his therapist on the weekends, and no one would know he's been uncomfortable unless he told them.  He's never been in a hospital, he's ultra-reliable, and he has great grades and extracurriculars.  Any way you look at it, Sam is an energetic guy on the road to success.


What should he write on the form?  It's a yes/no check box, no questions or place to clarify, so if he says yes, well, that could mean he has some subjective anxiety, or it could mean he has attention deficit problems, or it could mean he has been hospitalized 6 times after becoming violent, or has a severe mental illness.  He's worried that his anxiety will throw him into a subset of applicants that the committee would rather not deal with: why choose someone for a project who has a mental illness if another equally qualified applicant is available without this issue to address?


Sam's mother say he should check "yes."  He has been in treatment and he has a diagnosis and he takes a medicine.  He has a psychiatric disorder and he needs to be honest. 


Sam's father says that the question defies the spirit of what the committee wants to know.  They want to know, Dad presumes,  if there will be issues or problems or things they might need to accommodate, and there is no reason to believe that Sam's problem will interfere with his ability to negotiate life in a competitive or stressful environment.  Sam, he contends, does not belong in the same category as someone who has attempted suicide, been hospitalized, missed work, or behaved in a disruptive or dysfunctional manner. If anything, Sam's anxiety drives him to focus and achieve and to be very conscientious.  He's not ill, his father says, he's just more anxious on a spectrum of normal anxiety.


I want to know why forms get to ask such questions and put people in the awkward situation of having to answer something that is none of anyone's business versus being dishonest.  It seems that if someone wants to know this, it might be asked in terms of "Do you have any health issues that might require any special accommodation?"  Is there a limit to what random forms can ask and whether you're behaving unethically if you choose not to answer their questions or answer it less then completely?  Sam tried leaving the question blank, but the computer wouldn't let him submit the form without checking all the boxes first.  Can they ask if you have deviant sexual fantasies?  If you've ever committed a crime (regardless of whether you've been charged or convicted)?  If you say provocative things on your blog?

In Electronic Health Information, Who Decides Which Info is "Sensitive"?

I participate in a committee that establishes policies for our state's health information exchange (HIE). The HIE is the electronic infrastructure that permits hospitals, physician groups, labs, imaging companies, pharmacies, and others to share information about patients. The idea behind the sharing is to make it easier for your primary care doctor to share your health data (ideally, with your permission) with your cardiologist and your dermatologist. The potential benefits to this sharing include:

• quicker exchange of information than with faxing or mailing
• less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)
• better tracking of who accessed what information
• less duplication of tests ("I know you had a CAT scan at the other hospital last week but I can't wait for the results to be sent to me so I'm getting another one.")
• improved coordination of care
• fewer medical errors due to more information available
• decreased liability due to sharing of important information with other providers

The potential risks include:

• decreased privacy due to potential for data breach, identity theft
• loss of data due to technical problems (viruses, hardware failure, etc)
• failure to secure data due to inadequate authentication, authorization, encryption, etc
• more errors in health record due to automated data collection processes
• increased liability due to sharing of sensitive information with other providers

I wanted to talk briefly about this notion of "sensitive health information." Our committee has spent many hours discussing what this might mean and how to define it. One view is that all health information should be treated as "sensitive," while another is that only certain categories of health information, such as mental illness, substance abuse, HIV status, domestic violence, abortion history, and genetic data, should be treated with additional safeguards against inadvertent access or disclosure. This latter viewpoint promotes the stigma about mental illness that we have been trying to erase.  It wasn't so long ago that epilepsy and cancer might have been on this list. My viewpoint is that patients should be the one to decide which elements of their health information should be treated with extra precautions and which should be considered routine.

This was ultimately agreed upon by the other committee members, but it still didn't help us much because the technology for patients to review their health information and mark which bits should be tagged as sensitive is not yet built into nearly any of the electronic health record products or the HIE systems. There is no standard for doing so nor is there even any agreement about how or whether it should be done. Groups like healthdatarights.org and speakflower.org have promoted these ideals, but we are not much closer to achieving them.

Anyway, I discussed this topic in my Shrink Rap News blog post this week over on Clinical Psychiatry News. Read more about it over there. If you are a psychiatrist, log in or register on CPN and join the discussion (my mistake -- other professionals and also consumers are allowed to register over there).

Beards & Bow Ties

I stole this from Dr. Shock. It was written, directed, and narrated by Kamran Ahmed (no, not the Bollywood star -- the UK psychiatrist).
Seems like as good a time as any to turn on comment moderation.  Pretend you're in our living room.


And do join Clink in a discussion of tonight's CNN piece on St. Elizabeth's Hospital and the insanity defense.

Help Us Write Our Survey on the Public Face of Psychiatry!

Please Read This and Contribute Your Thoughts!

The Shrink Rappers will be hosting a workshop at this year's annual meeting for the American Psychiatric Association. We'll be talking on The Public Face of Psychiatry and of course we want to discuss the role of new media: blogs and tweets and podcasts and more. Clink will be discussing something forensic, Roy something techy.

But what is the Public Face of Psychiatry? We all believe that stigmatizing the mentally ill is a bad thing and deters people from getting care. And we all have thoughts on what helps and what hurts, but what do we actually know? There's not a lot out there on the topic. And it's not just the mentally ill, it's us Shrinks, we aren't exactly portrayed as the most regular of citizens by the media. One thing we will ask our workshop participants (thanks, Barb, for the great suggestion) is how people react at a party when the participant says they are a psychiatrist.

So what do I want from you? Well, eventually, I want you to take a survey and blast it around the blogosphere about attitudes towards psychiatry. I want it short, maybe 5 questions, so people will actually take it, and I'd like you to help me think about what those questions should be. So I'm going to start and I'd like your feedback in our comments section. Are my questions good? Should they be worded differently? Something short you might like me to add or remove or ask differently?

So here goes, and remember, this is pre-rough-draft, off the top of my head and the final questions will not look like this:


Psychiatry a) helps people b) harms people c) encourages people to use diagnostic labels as excuses for lazy or bad behavior d) is just about handing out medications

Psychiatric patients are a) regular people b) are people I'd rather avoid c) are deeper thinkers and more creative than others

Psychiatrists are a) creative, interesting people b) weirdos c) it's just another job and stereotypes don't apply d) are pawns of the pharmaceutical industry

Psychotherapy a) helps people b) encourages self-centered navel gazing c) often makes people feel or behave worse then they did before they entered treatment d) does nothing.

Psychotropic medications a) help people b) cause more difficulties then they cure c) are the creation of a greedy pharmaceutical industry which has deceived the public

Criminally insane patients are a) badly behaved people manipulating the system to stay out of jail b) deserving of treatment c) have the potential to return to free society d) should not live on my street

Electronic medical records (this one is potentially for Roy).... a) should exist exactly as all other medical records do in psychiatry and giving them 'special protections' increases the stigma of mental illness b) should not exist for psychiatric illnesses and treatment c) should exist but should have separate and higher protection to allow confidentiality.

A psychiatrist uses electronic medical records that can be accessed by my other physicians and I cannot restrict this: a) I would see this psychiatrist for care b) I would not see this psychiatrist for care

Direct-to-Consumer advertising (commercials/magazine ads) of medications: a) decreases the stigma associated with taking these medications and is therefore good b) scares prospective patients with the lists of side effects c) should not be used because it provides incomplete medical information and the suggestion that patients should demand specific treatments without individual consideration of the patient and their problems

Psychiatric blogs: a) are useful sources of information and I have found them to be helpful
b) are biased and unhelpful

Blogs about psychiatry in general (including those by patients and those who may be disenchanted with psychiatry) have a) encouraged me to get treatment or to recommend treatment to others b) have discouraged me from getting treatment or recommending psychiatric treatment to others.

Obviously, I need your help. Thank you so much and do let me know your thoughts!

Guest Blogger Dr. Robin Weiss on Stigma and Health Insurance Parity

I'm borrowing this from Robin, who wrote it a while back when she was our state psychiatric society's prez. A little background: Robin was a pediatrician, turned health policy expert, turned psychiatrist. I'm guessing that she didn't do her second residency training in psychiatry so that she could write prescriptions for 40 patients a day, but I could be wrong. Except that I'm not.

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Psychiatry has always seemed to me to be the most fundamental and inclusive medical specialty. What psychiatrists understand is this: Human illness is a dynamic function of genetics and environment, and genetics and environment are further influenced and changed by each other. So we understand that existential angst, psychodynamics, family structure, goodness of fit between parent and child, inborn temperament, neurotransmitters, brain structure and function, and more, are all part of the illness mix -- just as true listening, various forms of psychotherapy, and psychopharmacology are all part of the treatment. It is this understanding that elevates psychiatry to a model for all medical specialties. Furthermore, mental illness disrupts and damages those very human capacities that we value most -- our thinking, our emotional lives, and our behavior. I don’t mean to create a competition among the organs (pancreas, liver, kidney vs. mind/brain), but certainly those functions executed by the brain underlie all else. In light of all this, what could possibly account for psychiatric treatment’s peripheral, holding-on -by-the-skin-of-our-teeth insurance coverage status?

Dr. Myrna Weissman, in JAMA, wrote an editorial titled Stigma. She describes the experience of her friend’s fourteen year old son as he struggled with first, serious mental illness, and later, leukemia. What his mother encountered first was her insurance company’s refusal to authorize a comprehensive evaluation; a useless three day hospitalization leading to an episode with the legal system; blame for her son’s behavior; and more care provided by the education system than by the medical care system. What she encountered when he developed symptoms of leukemia was prompt diagnosis and full treatment; an expectation that there would be relapses; compassion and support; and full insurance coverage for hospitalizations, partial hospitalizations, and home care. Dr. Weissman concludes that the stigma associated with mental illness leads to lack of insurance parity, which leads to heartbreakingly bad care -- this, at a time when each week brings breathtaking new research findings about the etiologies of mental illnesses and their treatment.

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So what do you think? This paper was written in 2001. Has much changed? We hear a lot about psychiatry being under-funded because the research and the proof aren't there. It seems it can always be done with less (less time, less therapy, less hospital beds --okay, fewer hospital beds--, less expensive medications, less education) or so we're told. I personally think the insurance companies simply want to part with as little money as possible, and that certain illnesses garner more sympathy than others. Can you imagine the uproar if an insurance company refused to pay for a child's treatment for leukemia? And with all the push for parity, is it getting any better for psychiatry? Or is just getting worse for the other specialties?

Guns and the Mentally Ill

On Facebook, I'm a fan of NY Times Reporter Nicholas D. Kristof

Mr. Kristof's status reads today:

Nicholas D. Kristof

Just in case Pres. Obama visits my FB page, what should we suggest for his State of the Union speech? My hope is that he calls for banning oversize ammo magazines, like the 33-round one used in Tucson. Even Cheney favors a ban on them. And gun serial numbers that are harder to scratch out. And tighter restrictions on the mentally ill obtaining weapons. Your thoughts? Other suggestions for the President?

I'm not an NRA member (this is my disclaimer here) and I've never had much use for guns. But I had thoughts about the issue of "tighter restrictions on the mentally ill obtaining weapons."
I wondered what that meant and how one defines "the mentally ill." Oh, and my second disclaimer here is that I don't know how current regulations work in determining who is mentally ill with regards to purchasing a weapon. I've never reported to any central source any information about who I'm treating so they can't buy guns and no one has ever asked me to sign off on a gun permit. I'm not sure how it's determined that someone has a mental illness and shouldn't own a gun.

It doesn't take very much to get yourself into the range of being 'mentally ill.' Knock-on-door community studies, known as the ECA studies-- meaning Epidimeologic Catchment Area-- show that over half of all people have an episode of mental illness at some point. This includes phobias and anxiety disorders. NAMI tells us that one in five people have a serious mental illness.

Some of the people who commit crimes with legal guns haven't sought treatment. If you haven't gotten a diagnosis, how can you be designated mentally ill for gun ownership? Does gun ownership get designated by diagnosis? Certainly, owning a gun is not a great idea for a person with brittle bipolar disorder who gets violent and impulsive. But we all know that the diagnosis of 'bipolar' disorder has become a bit loose and over-inclusive. An angsty teenager sees a psychiatrist and is diagnosed with bipolar disorder. If he does well later, should he be forbidden from buying a gun at the age of 40? I believe one standard is a psychiatric hospitalization for over 30 days, but I'm not certain how--or if-- that's reported.

I suppose we worry about the Big Brother aspect here. Maybe instead of "mental illness" the standard should be that if college student is expelled, or an employee is fired, for certain behaviors then they are reported to a 'no-guns' data bank. Then you'd capture violent and threatening people who have not sought treatment but may well be dangerous. Oh, I'm just mouthing off here about something I admit that I know little about. But I hate finding one more thing to stigmatize mental illness over in a way that is not likely to effectively decrease gun violence.

Have a happy Facebook day, Mr. Kristof.

Any thoughts?

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.

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.

Fly Those Friendly Skies

We've talked before about whether having the diagnosis of a mental illness should prevent a person from pursuing certain careers. We've also mentioned that pilots, in particular, can not be on psychotropic medications. One concern is that a depressed pilot might not seek treatment because s/he fears losing her job. Is it better to have a pilot with untreated mental illness, or one on medication?

In The Wall Street Journal, Shirley S. Wang and Melanie Trottman write that the FAA has reconsidered this policy and will allow pilots to fly if they are being treated with Zoloft, Celexa, Lexapro, or Prozac. They write:

The new policy doesn't mean pilots who want to begin taking one of the medications can get in the cockpit right away. Before being granted a waiver by a physician certified by the FAA, a pilot must be considered "satisfactorily treated" for 12 months; in the meantime, he or she will be grounded.

For pilots who have been secretly taking antidepressants, the FAA is offering a grace period. The agency said it wouldn't take action against such pilots if they come forward within six months. However, pilots with a recent case of depression or who want to begin a new medication regimen will be subject to the one-year waiting period, according to FAA spokeswoman Alison Duquette. "We're really looking for stability," she said.

Grounded for 12 months? Seems like a long time. What do grounded pilots do? Do they get paid? Is this really destigmatization?

Can We MAKE You Crazy?

In today's NY Times Magazine, Ethan Watters discusses cultural influences in the etiology and expression of mental illnesses in his article entitled "The Americanization of Mental Illness." Watters is not a big a big proponent of the idea that psychiatric disorders are brain-based diseases, and he points to ways that Western ideas have changed the incidence and thinking in other parts of the world. Watters writes:

Western mental-health practitioners often prefer to believe that the 844 pages of the DSM-IV prior to the inclusion of culture-bound syndromes describe real disorders of the mind, illnesses with symptomatology and outcomes relatively unaffected by shifting cultural beliefs. And, it logically follows, if these disorders are unaffected by culture, then they are surely universal to humans everywhere. In this view, the DSM is a field guide to the world’s psyche, and applying it around the world represents simply the brave march of scientific knowledge.

Of course, we can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. Modern science has begun to reveal these causes. Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening. Those stories, whether they tell of spirit possession, semen loss or serotonin depletion, predict and shape the course of the illness in dramatic and often counterintuitive ways. In the end, what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations today as hysterical-leg paralysis or the vapors or zar or any other mental illness ever experienced in the history of human madness. This does not mean that these illnesses and the pain associated with them are not real, or that sufferers deliberately shape their symptoms to fit a certain cultural niche. It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.

Watters then goes on to ask if the medicalization of mental illness does in fact lead to destigmatization. He cites a study where college students give bigger shocks to test subjects trying to learn a new task if they believe the test subject has a mental illness caused by a biological problem rather than a childhood problem. I'll skip even thinking about this study, but why do so many studies have college students shocking each other? Shouldn't they just hit each other with baseball bats?

Watters goes on to conclude:

CROSS-CULTURAL psychiatrists have pointed out that the mental-health ideas we export to the world are rarely unadulterated scientific facts and never culturally neutral. “Western mental-health discourse introduces core components of Western culture, including a theory of human nature, a definition of personhood, a sense of time and memory and a source of moral authority. None of this is universal,” Derek Summerfield of the Institute of Psychiatry in London observes. He has also written: “The problem is the overall thrust that comes from being at the heart of the one globalizing culture. It is as if one version of human nature is being presented as definitive, and one set of ideas about pain and suffering. . . . There is no one definitive psychology.”

Do the Kids Do it Differently?

We've been talking about stigma and whether someone should tell people they suffer from a mental illness. I've said that some people advertise their illnesses and it draws people in, while other do it and find they are shunned. Commenters have had a variety of responses, but most votes go against telling people one has a mental disorder.

Does it matter what you have? Or how much it's disabled you? Or how it's framed? I talked about the chemistry teacher on antidepressants (and yes, the demographics were changed)--- she framed it as she was having a hard time after a major loss, not that she was suffering from a major mental illness that might effect her current behavior or reliability.

So is it different for the kids? They've grown up on Cymbalta, Zoloft, and Viagra commercials. They've posted their lives on MySpace and Facebook. When I think about my kids' friends, I have to say they are all pretty open about psychiatric illnesses-- I've had kids spend the night who take psychiatric meds, I've had little peeps point out a window and say, "That's where my psychiatrist is." I've heard that Sal and Hal both see the same therapist, that Bobby's been in treatment for anger issues, that Tom, Dick, and Harry are all on ADD meds. I've had a physician tell me about his depression and his family's therapy while we watched our kids' compete (and the whole teams' parents listened on). Back in the day when big pharma distributed pens, my kids would take them to school and other kids would volunteer, Hey I take that! When I think about it, I know a lot of kids who've had a lot of treatment.

ugh...blogger won't let me add a pic...

To Tell or Not to Tell? That is the Question.

Should patients with psychiatric disorders discuss them openly? Is it better to let it be known like it's no big deal, or to hold on tight to those secrets? We've talked about this a lot when we've talked about the meaning, the stigma, and the consequences of psychiatric labels. It seems to me that some people advertise their problems and are no more worse for the wear: they start talking at a party about how they have bipolar disorder and suddenly they are the magnet for everyone else's bipolar stories. It's refreshing, in a way, how free they feel to be open. Perhaps some of it is career-dependent: certainly it's more permissible among artists and musicians to have suffered, and some problems with mood or substances can be so much a part of landscape as to defy stigma.

Why now am I bringing this up? Carpool today: "We talked about therapy and antidepressants in chemistry." Hmmm, that's not chemistry, shouldn't they be balancing acid-base problems? "And what does your teacher have to say about it?" Apparently the teacher was on antidepressants for years during a difficult time, but she suggested the whole class probably had issues and things to talk about in therapy. Why not?

What do I think? This is a young, well-loved and respected teacher. If she's comfortable telling the kids that treatment has helped her, more power to her. Maybe someday some troubled person will figure Ms. Chemistry was cool with it and will get help. As long as they get to the acid-base stuff eventually.

Glenn Close on the Stigma of Mental Illness

Thanks to Laszlo for sharing this piece from The Huffington Post.

Actress Glenn Close writes about "Mental Illness: The Stigma of Silence:"

It is an odd paradox that a society, which can now speak openly and unabashedly about topics that were once unspeakable, still remains largely silent when it comes to mental illness. This month, for example, NFL players are rumbling onto the field in pink cleats and sweatbands to raise awareness about breast cancer. On December 1st, World AIDS Day will engage political and health care leaders from every part of the globe. Illnesses that were once discussed only in hushed tones are now part of healthy conversation and activism.

Yet when it comes to bipolar disorder, post-traumatic stress, schizophrenia or depression, an uncharacteristic coyness takes over. We often say nothing. The mentally ill frighten and embarrass us. And so we marginalize the people who most need our acceptance.

What mental health needs is more sunlight, more candor, more unashamed conversation about illnesses that affect not only individuals, but their families as well. Our society ought to understand that many people with mental illness, given the right treatment, can be full participants in our society.

Read more at: http://www.huffingtonpost.com/glenn-close/mental-illness-the-stigma_b_328591.html

Seems like a good follow-up to our discussion of whether only perfect people should have children.

Demystify Me!

We have a blog, we have a podcast, ShrinkRapRoy does some tech/med/psych twittering, and now we're writing a book. We've given one talk together, and once we're finished writing the book, we'll plan to do more as part of marketing the book (and the blog, and the to-be-resumed podcast) There's nothing to say we won't find more projects that compel us as time and technology move on. It's got me thinking that we need some umbrella organization to encompass all the different aspects of our work. I had a quickly-thought-of name; Clink says she can do better. Roy asked what our purpose would be and I assured him we'd have a mission statement, something to do with promoting dialogue, demytifying psychiatry, and decreasing stigma for mental illness. Roy added that we'd want to promote the destigmatization of both psychiatrists and the treatment of mental illness.

It got me thinking about what we do, and the issue of demystifying psychiatry. Do people want their psychiatrists/therapists demystified? Is there something about having that element...that distance, that assumption that the therapist is a little bit mysterious, unreachable, or somehow special in a way that regular people aren't, that is helpful (even if it's just not true)? Sometimes my patients ask questions about my life, or express surprise that I'd like, or do, something that isn't in keeping with the image they hold of me. What might be uncovered? Maybe that doc eagerly taking notes is actually writing a letter to his mistress (I hope not!) or behind the wise therapist fascade is an ordinary person stressing about bills, or a sick parent, or an ornery child, or their own irritable bowel. So demystify or leave it all alone?

On a totally different note: Roy got a New Puppy today. Oh my, is it precious. I went over to bond and the little guy (and he is little) curled up and slept on me.

Midwife With A Knife: Infertility, Stress, and Psychotherapy

Okay, so I'm behind the times, here's a cool post from Midwife With A Knife from 2 months ago-- an interesting post on fertility, stress, and psychotherapy. Oh, and lemurs and monkeys and all kinds of critters, fertile and otherwise. I'm even stealing her lemur photos. I can't quite get the link right but it's the post called "Are you reading my blog?"

MWAK asks how to tell stress-susceptible people they may benefit from psychotherapy without making it sound like you think they are wusses (her word, isn't it great?!). What do you think?

I've never seen anyone for a primary complaint of "I can't conceive" but I face this problem regularly with pain patients. I'm left to say that some people's depression gets funneled into their body as pain or physical symptoms, and it's remarkable how treating the depression can alleviate the other symptoms. I could have sworn I once wrote a post called "You Need a Psychiatrist" about how to talk to people about getting care without sounding judgmental, but I can't seem to find it---must have been a dream.

So for tags we have pregnant pigs, bears, turtles, vultures, fish, glow in the dark cats, but no lemurs or monkeys. What kind of blog is this anyway?