What I Learned Part 2

Oh my, it's hard to keep my mind on professional things when I see a hurricane headed toward my home. The airline says they're not expecting it to affect my flight back, but I'll believe that when I see it.

But on to the conference...

The poster session was notable for a nice outcome study done in Georgia about the efficacy and cost impact of a jail-based competency restoration program. Another poster about assisted outpatient treatment in New York showed that there was considerable variation in willingness to seek outpatient commitment, possibly related to available outpatient services. There was a presentation about the use of restraints in pregnant psychiatric patients which was interesting. There was a national survey of mental health program directors which showed that up to 80% of responding systems had no established policy about this.

There was a panel presentation about the AAPL guidelines for sanity evaluations, which are being updated. Members were given the opportunity to comment upon the current guidelines and any issues that needed to be revised.

I was pleased to see ethics featured prominently at this conference, including a very informative panel presentation about the process by which AAPL and APA manage ethical complaints and the difficulties writing and enforcing professional guidelines. I learned that about 10 to 15% of ethical complaints to APA district branches are related to forensic issues.

The luncheon speaker was David Kaczynski, brother to the infamous Unabomber Theodore Kaczynski. He gave a very moving talk about his early life with his older brother, Kaczynski's gradual withdrawal from his family and society in general, and the slowly growing realization that his older brother was indeed a killer. He talked about his struggle to come to terms with his suspicions, the impact on his elderly mother and what it felt like to be caught between preventing future murders and potentially sending his brother to a death sentence. He talked about his work after the trial, reconciling with some of the victim's families. My most memorable quote: "Teddy's bombs destroyed lives, but healing is possible."

The early afternoon session was a smorgasboard of random topics. There was a survey of judges regarding their willingness to allow defendants to represent themselves at court (pro se defenses). Judge weight heavily the defendant's ability to understand the risk of a pro se defense and the defendant's willingness to accept standby counselor. Psychiatric input is considered, but mainly as it related to a description of symptoms and impairment rather than the ultimate opinion of competence. There was a description of a telepsychiatry program used in the New York prison system, where fourteen facilities used teleconferencing to provide over 12,000 patient contacts in one year.

Finally, the secondary them of this conference appears to be the use of psychological tests by psychiatrists. The last session of the day was entitled "Psychology vs Psychiatry in Risk Assessment". The panel presented individual cases and general principles related to the use of violence prediction instruments and how they are currently used in forensic work. The limitations of these instruments were also discussed, which was interesting because this is not something that often gets discussed by those who use them (at least in my experience). One example of this was the use of a violence risk instrument for conditional release. Since the risk of dangerousness must be due to a mental illness, and since the instrument did not rely upon illness-based dangerousness, the instrument was not relevant to the legal question at issue.

So that was the day. You can follow my live tweets from the conference at: www.twitter.com/clinkshrink

My Three Shrinks Podcast 49: Pixelated Psychiatrists

For today's podcast we have guest psychiatrist Dr. Pat Barta talking about telepsychiatry, telemedicine and all things neuroimaging. We ponder how licensure works for telepsychiatry, whether or not you can get reimbursed for it, what the difference is between a face-to-face evaluation versus a telephone interview and why we don't yet have an iPhone app to diagnose schizophrenia. All of these topics (and more) can be found on Dr. Barta's blog Adventures in Telepsychiatry.

We talk about Pauline Chen's article in the New York Times: "Are Doctors Ready for Virtual Visits?"

Roy, Dinah, Pat and Clink discuss electronic health records and who should have the rights to our personal health information. I'm including a link to the Speak Flower web site, an organization dedicated to promoting patient-controlled health information systems.

We also hear from Dinah's new dog. Please go to iTunes and write a review.

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Find show notes with links at: http://mythreeshrinks.com. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom). This podcast is available on iTunes (feel free to post a review) or as an RSS feedorFeedburner feed. You can also listen to or download the .mp3 or the MPEG-4 file frommythreeshrinks.com. Thank you for listening.

TeleMental Health Services Needed

via HITshrink:




Two feet of snow and Baltimore comes to a screeching halt. How to get the doctors to the hospital? This is where telepsychiatry can be very helpful. However, there are still so many impediments to using telemedicine (billing, liability, documentation, technical) that we are *still* unable to use it when we need it. Like today, where the hospital will have to send a 4x4 to pick up Dr Chandran to get him to the hospital.

A broader term for distance mental health services is Telemental Health services, or TMH. Proposed new regulations were released last week that would permit and regulate TMH under the public mental health system (aka Medicaid) in Maryland. Unfortunately, the way it is currently written would not permit me to "see" inpatients on our unit from home during a blizzard. Still, it is a step in the right direction.

For more info on TMH, check out the Maryland Telemental Health website.

Skype Therapy

So what do you think about the idea of videochatting with your shrink on the computer? Patrick Barta is a psychiatrist in Maryland who has started having some of his sessions (5 percent or so) on Skype. He's blogging about his experiences and talking about the good and the bad aspects. Do visit his blog: Adventures in Telepsychiatry and let him know what you think about Skype-Therapy!

CBT4CBT

I heard a talk today on CBT4CBT: Computer Based Training for Cognitive Behavior Therapy where substance abuse treatment is supplemented with On-line real-time psychotherapy groups. I hope I'm saying this right.

The patients go to regular appointments, but in addition, there is an on-line group. The patients and a therapist all 'meet' at a pre-arranged time. There is a camera on the therapist, so his image pops up in the corner of the screen. He can write on the main part of the screen. The participants call in over their computers (each is given a microphone). They're aren't seen, but they have screen names, and they talk one at a time: they press a button to speak and release it when they are done, assuring that people don't talk over one another (I could use one of these buttons in real life). All the patients liked it and they did as well as the controls who had real-life treatment without the supplemental on-line group.

Here's a link if you want to read about this stuff.

And the talk I heard used a platform designed by eGetgoing, an online substance abuse treatment service. I learned something new today.

After the Data: More on the Phone Therapy Study.

Okay, if you read my last post, you know I ranted (who me, rant?) about Tara Parker-Pope's NYTimes Well blog post where she asserted that phone therapy is effective for Depression-- as effective as real life therapy with less attrition. People wrote in to talk about their feelings about phone therapy, but really my gripe was with the idea of presenting a conclusion without any details-- I had a lot of questions about how this conclusion was reached, and I thought perhaps there were only 12 patients in the study.

So I emailed the author of the study, David C. Mohr, pH.D. at Northwestern, and within hours, I had a reprint of the study. It was a lot of data and I only did a quick read, but my questions were all answered, and here's the scoop:

This wasn't a research study: the journal article is a review of the literature of ALL phone therapy studies done, and 51 such studies were identified. All but 12 were excluded because they did not meet the authors' specific criteria to be included-- for example, some were surveys, not therapy trials, and any study that had ANY face-to-face contact was excluded. Mohr goes into detailed discussions of therapist training, treatment orientation, co-morbid illnesses, treatment format, and other variables. Mohr discusses how many of the patients and control subjects may have been on medications prescribed by primary care doctors or oncologists (--some of the studies looked at phone therapy in patients suffering from specific illnesses). I couldn't find any data from these studies that revealed that phone therapy worked as well as the traditional in-person stuff in a face off controlled trial.

The Well blog said: "The researchers also found that telephone therapy was just as effective at reducing depressive symptoms as face-to-face treatment."

Actually, the researchers wrote:
We also want to emphasize that it is premature to generalize the results of this meta-analysis broadly. Individual studies suggest specific uses under specific circumstances; for example, telephone therapies may provide added benefit compared to care for depressive symptoms by a primarycare physician or to no care at all. However, because the depression symptom outcomes used in this meta-analysis were self-report instruments, the generalizability of these findings to clinically diagnosable depressive disorders is limited (Kendall & Flannery-Schroeder, 1995). Furthermore, the measures of depression used in this study had a wide range of specificity and sensitivity (Minami, Wampold, Serlin, Kircher, & Brown, 2007). Thus, the aggregated effect size estimates for depressive symptom severity should not be used as any sort of benchmark. In addition, the level of heterogeneity across studies suggests that we do not yet understand the characteristics of patients for whom such telephone interventions may be effective, and those for whom telephone intervention may not be appropriate. The heterogeneity in the severity of depressive symptoms and in medical comorbidities in the samples also limits generalizability.

AA noted in his/her comments that we here at Shrink Rap sometimes make statements without fully backing them up or giving a full assessment of the literature. I have to agree. We're rambling for fun, we try to be accurate, we look up and link, but psychiatry is sometimes vague, still a mix of art and science with more questions than answers and the it never ceases to amaze me that how differently individuals react to the same intervention-- be it a word muttered or a medication prescribed. We try to be careful, but we can't be exact and some of this is about ducks and chocolate and us just venting about our days. I promise, however, that the moment the New York Times wants to pay me a salary to do this, I'll become really really careful about the conclusions I draw!

Thanks to Dr. Mohr for providing the paper:
The Effect of Telephone-Administered Psychotherapy on Symptoms of Depression and Attrition: A Meta-Analysis David C. Mohr, Northwestern University, Hines Veterans Administration Hospital Lea Vella, San Diego State University Stacey Hart, Ryerson University Timothy Heckman, Ohio University Gregory Simon, Group Health Cooperative

I Want To See Your Data

I've been resisting the urge to write about it, but Rach ( in her leg-warmers) has asked, so here are my comments about Tara Parker-Pope's New York Times Well blog called The Benefits of Therapy by Phone. It's a short piece, minus comments, so I'm simply going to paste the whole post. Ms. Parker Pope writes:

The Benefits of Therapy by Phone

Phone-based therapy can be less hassle for patients. (Peter DaSilva for the New York Times)

Most therapists schedule face-to-face meetings with their patients. But new data suggest that therapy by phone may be a better option for some patients.

It has long been a concern among therapists that nearly half of their patients quit after only a few sessions. As a result, a number of health care providers and employee-assistance programs now offer therapy services by phone.

A new analysis of phone therapy research by Northwestern University shows that when patients receive psychotherapy for depression over the phone, more than 90 percent continue with it. The research showed that the average attrition rate in the telephone therapy was only 7.6 percent, compared to nearly 50 percent in face-to-face therapy. The researchers also found that telephone therapy was just as effective at reducing depressive symptoms as face-to-face treatment.

“The problem with face-to-face treatment has always been very few people who can benefit from it actually receive it because of emotional and structural barriers,” said David Mohr, professor of preventive medicine at the Feinberg School of Medicine and lead author of the study, published in the September issue of Clinical Psychology: Science and Practice. “The telephone is a tool that allows the therapists to reach out to patients, rather than requiring that patients reach out to therapists.”

Among patients who say they want psychotherapy, only 20 percent actually show up for a referral, and half later drop out of treatment.

Dr. Mohr said he began using phone therapy because he was working with patients who had multiple sclerosis who could not get to a therapist’s office. Some patients don’t have regular transportation to a therapist’s office or can’t take time off work or away from their families. In addition, a patient with depression may simply not be capable of getting themselves to the therapist’s office on a regular basis.

“One of the symptoms of depression is people lose motivation,” Dr. Mohr said. “It’s hard for them to do the things they are supposed to do. Showing up for appointments is one of those things.”

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Where should I begin? I'll guess I'll start by saying I don't want to talk about the value of phone therapy. Certainly, phone contact between sessions can help alleviate a crisis and may provide some comfort to a patient, but this isn't about 'between-sessions' with a known live entity, it's about telephone contact in place of live sessions, and my understanding is that this is from the get go.

It's a blog post, not a rigorous scientific article, but I'm going to start by saying I thought the post is irresponsible. That feels strong, and I'm an avid Well reader, but it's full of all these blanket statements, given as facts, with nothing that backs them up. There's a link to an abstract, and an email to request the full article, but I'm going to note that the abstract also gives very little information about the methods used and the conclusions reached. I didn't write for a copy of the full article (I will) -- maybe it was great science that warrants the conclusion that phone therapy for depression is as good as live therapy, but it's hard to get there from either the blog post or the abstract. Stay tuned: we'll use the full article for a future My Three Shrinks podcast.

Okay: The article starts by saying that therapists are concerned about patients leaving after only a few sessions. Is this true? Maybe people feel helped and leave. Maybe the therapist is horrible and they leave. And actually, insurance companies judge the best shrinks as those whose patients come the fewest times (presumably the quickest cured, but certainly the cheapest for the insurance company).

The next interesting assertion is that only 20% of people who want psychotherapy come for treatment? How do we know this? I suppose there could be a number for those who initiate treatment, but for those who Want?

Moving along, the issue is one for treatment of Depression, nothing is said about any other disorder, and I was left to wonder how the diagnosis was made: presumably over the phone? Is it just patients who self-diagnosed as Depressed? If a patient phone screened for another illness, were these results omitted so the finding could be positive for Depression? And is medication an option or perhaps these patients were identified by primary care docs who had already made the diagnosis and prescribed the medications? We have no idea what the pool of patients was, if medication has a role, or whether the patient or therapist initiated the calls. We do know that few dropped out of treatment: I do agree it's easier to call in than to deal with the hassles of getting to an appointment, but perhaps it's even easier if the therapist is doing the calling and the at-home patient (or on the cell out-and-about) just needs to answer the phone. How long did the patient need to remain engaged for the session to be called "therapy?"

And the patients got better, compared to controls, but even the abstract doesn't tell us if the control group is a face-to-face therapy cohort or a no-treatment group. There are no rating scales, no average score changes, not even a mention of how many patients were involved. The abstract says '12 trials of psychotherapy' so I'm thinking this means 12 patients. If so, that's hardly a number that has any real meaning as a measure to influence standards of care and attract the attention of the New York Times and I'll return to the word irresponsible. What happens when the person at the other end of the phone is acutely suicidal? What happens when a patient lodges a complaint against a phone therapist who isn't licensed in their state? And might I wonder if insurance companies could use such articles as rationale for out-sourcing psychotherapy to phone sessions with therapists in other regions where care might be cheaper? I'll leave that one to your imagination.

My Three Shrinks Podcast 38: New & Improved!

[37] . . . [38] . . . [39] . . . [All]

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Okay, this podcast is a milestone for us. Dinah bought several hundred dollars worth of sound equipment (Alesis MultiMix8 w/Firewire, Behringer C-1 mics), which took us several hours to properly set up to record so that each of us comes into the MacBook as a separate track, thus letting us have more equal sound volumes (before we all shared the same mic, so our voices were at different levels).

I've set it up so that if you listen to the .m4a version (that's what gets downloaded from iTunes), Clink's more on the left channel, Dinah's more on the right, and I'm in the middle. Let us know how you like it. I'm still figuring out how to use it all to achieve the best sound quality, but I think #38 is the best one we've ever done so far.

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November 11, 2007: #38 New & Improved!


Topics include:

• MacArthur Foundation Grant. Decision-making, substance abuse, and brain abnormalities. Developing guidelines for judges about neuroimaging and brain function.
  
  
• On our Shrink Rap blog, Clink blogs about What She Learned (Part 1, Part 2, and Part 3) at her AAPL conference.
  
  
• Delirium. Roy discusses delirium, or encephalopathy, what it is and recent findings about longer term damage. This was on the front page of a recent WSJ.
  
  
• Shrink-proof containers. Clink brings back a hotel bottle of mouthwash that she could not open.
  
  
• Q&A: Gerbil brings up recent study on chocolate lovers.
  
  
• Online CBT for Depression. Study finds it helpful for mild-moderate depression. Eliza.
  
  
• Telepsychiatry. We just chat about some of the issues.
  

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Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.