Suicide Rates Shoot Up in Youths

Dennis O'Brien reports in today's Baltimore Sun that the suicide rates in children and adolescents have increased since 2004, after over a decade of decreases. It was in 2004 that the US FDA decided to add black box warnings to antidepressants stating that they may increase the risk of suicide or suicidal thoughts. Many speculate that the sudden and dramatic increase is related to the 22% decrease in antidepressant prescriptions in this same population.

As noted in our review of a June 2007 AJP article in Podcast #26 (Black Box Reloaded), there was a 58% drop in the expected number of antidepressant prescriptions for kids after the black box was added, while the proportion of depressed children who remained untreated with antidepressants increased some three-fold, going from 20% to 60% (see dramatic graph). At least at last year's FDA hearing, they decided to make a more measured warning, noting that antidepressant medication treatment can be protective and reduce suicidality, as well.

O'Brien wrote:

Among people ages 10 to 24, the number of suicides jumped from 4,258 to 4,599 in 2004, the most significant rise in teen suicides in 14 years, according to a report by the Centers for Disease Control and Prevention. That reverses a 28 percent slide in suicide rates for the age group that began in 1990.
. . .
"There's been concern that the black box would lead to a reduction in prescribing and therefore an increase in suicides, and my guess is that's what's happening," said Dr. Mark Riddle, director of child and adolescent psychiatry at the Johns Hopkins Children's Center.

Some doctors are reluctant to prescribe an antidepressant to a child if it comes with the FDA's most stringent warning label, Riddle said: "People see it as a potential feeding frenzy for the malpractice lawyers and it's just scared the clinicians off."
. . .
But other outside experts were reluctant to link the black box warnings with a one-year rise in suicides. . . "There are so many social issues that go into suicide rates and how they're reported."

We also reviewed two other articles (Simon & Savarino and Gibbons et al) about the timing of suicide and treatment in Podcast #30 (Parity Feels Like a Bird). These articles point to increased rates of suicide attempts prior to the initiation of either antidepressant or psychotherapeutic treatments.

The September 2007 AJP article by Gibbons et al (a different article than the Gibbons article above) that is mentioned in the Baltimore Sun story provides data on reductions in antidepressant prescriptions by age category since 2004, clearly showing that the reductions are most pronounced in the youngest age groups and become less so with older groups. The only group with an increase in prescription rates is 60 years and older. This is the age group which the FDA has found to be most clearly protected by antidepressant treatment.

The article, entitled "Early Evidence on the Effects of Regulators’ Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents," concludes with the following warning:

In December 2006, the FDA’s Psychopharmacologic Drugs Advisory Committee recommended that the black box warning be extended to cover young adults, and in May 2007, the FDA asked drug manufacturers to revise their labels accordingly. If the intent of the pediatric black box warning was to save lives, the warning failed, and in fact it may have had the opposite effect; more children and adolescents have committed suicide since it was introduced. If as a result of extending the black box warning to adults there is a 20% decrease in SSRI prescriptions in the general population, we predict that it will result in 3,040 more suicides (a 10% increase) in 1 year (17). If the FDA’s goal is to ensure that children and adults treated with antidepressants receive adequate follow-up care to better detect and treat emergent suicidal thoughts, the current black box warning is not a useful approach; what should be considered instead is better education and training of physicians.

The Reality (TV) of Jail

OK, I just saw the first episode of the new reality TV show, Jail, on WUTB last night. I understand this is a remake of the cable show Inside American Jail from Court TV but I've never seen that since I don't have cable. Anyway, this really is a show people should see. It was created by the same people who made Cops, and it's based on the same premise. The show follows sheriffs around as they process new arrestees at various large urban jails.

Last night's episode featured lots of people under the influence of drugs and/or alcohol. It showed the booking process, the intake medical screening process and the suicide prevention measures. It gave a good glimpse of the people who come to jail, why they come there and the condition they're in on arrival. It was easy to pick out the detainees with altered mental states but not nearly so easy to tell whether that change was from psychiatric problems or substance abuse. One pretrial detainee highlighted the medical problems jails deal with---he had a single tooth hanging from his upper jaw. When the officer doing medical screening asked him if he had dental problems, he burst out laughing.

The episode I saw featured three different large urban jails. All the jails were more spacious, cleaner and quieter than the ones I've been in. Maybe it was just a good time of night, but I was surprised to see their booking cells only held one or two people at a time. There was no obvious blatant profanity or shouting, but then again with the FCC fines being what they are I'm sure the networks would screen this out. I thought the show did a good job of illustrating the plight of the average new arrestee. As one first-time offender put it, "My bond is only $400 and a lot of people here have it a lot higher, but when you've got nothing it might as well be a million."

Some folks may feel a bit of guilty voyeurism watching this show, but let this pass: This show should be mandatory viewing for all people who want 'tough on crime' policies.

Guest Blogger Ron Pies-- Religion & Psychotherapy: Two Armed Camps or Allies of the Soul?

Hey, I made a friend on Shrink Rap!

Dr. Ron Pies is a Professor of Psychiatry at both Tufts and S.U.N.Y. Upstate Medical University and I met him when he surfed over to read Don't Shrink Me. Ron is the author of The Ethics of the Sages (Rowman & Littlefield) and the upcoming book, Everything Has Two Handles: The Stoic’s Guide to Happiness (to be published in Spring, 2008 by University Press of America). Ron is a prolific writer and his work includes some fiction (we like that here). Finally, he's Editor-in-Chief of Psychiatric Times. I invited Dr. Pies to be a guest blogger, and here's what he sent:

Religion and Psychotherapy: Two Armed Camps Or Allies of the Soul?

Religion did not sit well with the early psychoanalysts. Although Freud’s views evolved over the many years he spent analyzing religion, he generally explained religion as a kind of neurotic “compromise”: focused as it is on an all-powerful “Father-God”, religion allows us to admit our vulnerability in the world, while also giving us a feeling of superiority and control. We become “God’s children”, develop all kinds of rituals and prayers designed to gain God’s good will, and thereby secure our place in the scheme of things. [I am oversimplifying greatly—for those interested in Freud’s views on religion, I recommend the web site of Prof. Jurgen Braungardt, a philosopher and psychotherapist]. For Freud and most of the early psychoanalysts, religion was a sort of childish problem to be, well, outgrown—often through the aid of psychoanalysis. Modern-day critiques of religion—witness the spate of books by Daniel Dennett (Breaking the Spell), Sam Harris (The End of Faith ) and many others—also focus on the supposed “irrational” or extremist elements of religious faith.

There is some truth to these critiques of religion, but in many ways, they obscure as much as they illuminate. For no matter how many theories we devise as to how religion arose, or what “neurotic” needs it may serve, we will never succeed in refuting the basic claims of most conventional religions; i.e., that there is a “Superior Being” of some sort; that this Being created and guides the universe; and that we are all governed by universal and “God-given” moral principles. There are simply no scientific experiments that could conceivably refute these claims—for no matter how many failed attempts to “detect” such a Superior Being, it is always possible that the very next experiment would succeed. And even if religion first arose out of some neurotic need to keep “Big Daddy” happy and on our side, this does not disprove the existence of a Father or Mother (or any other) God. (Imagine a primitive tribe that had a “neurotic need” to believe in tiny, sub-microscopic particles—this would hardly serve as evidence against the existence of atoms!).

But there is a deeper and—from my perspective as a psychiatrist—more important sense in which the critics of religion have missed the proverbial boat. This involves their failure to distinguish what I would call pathological religiosity from the religious impulse. Think about it this way. Mr. A. is convinced not only that his religion is valid, but that it is the only “true faith”, and that everybody else is a “heretic”. Mr. A. is completely impervious to any attempts to challenge his beliefs, rituals, or religious practices. Any attempt to do so sends Mr. A. into fits of frothing rage, and violent fantasies of “avenging the slur against the One True Faith.” Furthermore, when Mr. A. violates his own religious commandments, he is thrown into deep bouts of self-hatred and depression.

Sound familiar? Mr. A’s relationship to his religion encapsulates, in my view, a certain type of fanaticism that has become all too familiar in our age. (Fanaticism, by the way, can exist in folks of any faith, or no faith at all—it is a psychological type, not a religious label). Mr. A’s religiosity is clearly at odds with most traditional goals of psychotherapy; namely, reducing excessive guilt and anger, broadening the individual’s perspective on life, and increasing the patient’s “cognitive flexibility”. Mr. A. would be one tough customer in psychotherapy!

Now consider Ms. B. She describes herself as “not a religiously observant” individual, but one who does attend religious services “when I’m feeling a little lost or alone.” Ms. B. is not sure she believes in an all-knowing, all-powerful God; however, she says that, “I feel like there is something out there greater than us—some kind of order or intelligence in the universe that I feel drawn to very strongly.” Ms. B. has undertaken psychotherapy in order to “help me figure out who I am, and where I’m headed—like, is there a purpose to life beyond just working and getting by?”

Ms. B.’s relationship to faith is clearly very different in tone and content from that of Mr. A. Indeed, Ms. B would find little difficulty relating to many traditional psychotherapists, all other things being equal. In fact, one type of psychotherapy, called Existential Therapy, would be nicely suited to the kind of exploration Ms. B. is seeking. She represents what I call the religious impulse—a yearning for something larger than ourselves, often manifest as a sense of awe, mystery, or ineffable bliss. (The word “religion” is probably derived from the Latin, ligare, meaning to “bind” or “connect”—as in feeling “connected” to some larger community, set of laws, or spiritual purpose). I believe Freud would be quite wrong in regarding Ms. B’s religious impulse as “neurotic” in any way. Her sense of wonder and awe is certainly not a feeling I would ever want to “outgrow.” On the contrary, Ms. B’s powerful attraction to some transcendent “order or intelligence” in the universe is quite like the feeling expressed by Albert Einstein—arguably the greatest scientist since Isaac Newton. Einstein said
"Try and penetrate with our limited means the secrets of nature, and you will find that, behind all the discernible concatenations, there remains something subtle, intangible and inexplicable. Veneration for this force beyond anything that we can comprehend is my religion. To that extent I am, in point of fact, religious.”¹

Not only should psychotherapy be tolerant of this mature kind of religious impulse, its goals should be compatible with those of such a seeker. This is not to say that psychotherapy should be intolerant of more conventional or orthodox forms of faith; it is just to say that, in so far as the religious impulse veers over into pathological religiosity, its difficulties with traditional psychotherapy will multiply.

In my book, The Ethics of the Sages, I try to show how several different religious faiths hold views compatible with those of cognitive-behavioral therapy (CBT). For example, in the Jewish tradition, we are instructed, “…do not consider yourself wicked.”

[Pirke Avot 2:18]. The rabbis believed that, while we could certainly judge our individual acts as “wicked”, we should not entirely condemn our very being. (Hence, the modern-day expression, “Hate the sin, not the sinner.”). All this is quite compatible with a type of CBT developed by Dr. Albert Ellis, known as Rational Emotive Behavioral Therapy (REBT). Ellis (who died just recently) argued that, “If human beings have any intrinsic worth or value, they have it by virtue of their mere existence, their being, rather than because of anything they do to “earn” it...You are “good” or “deserving” just because you are…” ²

Similarly, in another portion of the Talmud [Pirkei Avot 2:21], we are told, “...it is not up to you to complete the task, but you are not free to desist from it...” This teaching is part of a powerful "anti-perfectionism" in Judaism. It tells us, in effect, “Don’t condemn yourself if you don’t finish everything successfully—but don’t just give up on it, either.” This is quite consonant with the position taken by Ellis and Harper: “People who lead a lazy, passive existence...are almost always (consciously or unconsciously) defending themselves against some irrational fear, especially the great fear of failure. Viewing failure with horror, they avoid certain activities that they would really like to engage in...” (A Guide to Rational Living, p. 174).

There are many such fruitful intersections between psychotherapy and various religious traditions. The values of psychotherapy—and let us be clear, there are such values—may never coincide completely with those of traditional religion; but neither do psychotherapists and the religiously faithful need to be adversaries. Though they proceed from different premises and may seek different goals, psychotherapy and religion may yet be “allies of the soul.”

Albert Einstein, Response to atheist, Alfred Kerr (1927), quoted in The Diary of a Cosmopolitan (1971)

Ellis A, Harper RA: A Guide to Rational Living; No. Hollywood, Wilshire Book Co., 1971, p. 89

How to Raise Teenagers: I Must Have Slept Through That Lecture

Those of you who are regular readers may recall that in addition to being a psychiatrist, writer, and podcasting blogger, I am also the mother of two teenagers. It's okay, no surprises here, after all I went to medical school and I'm a psychiatrist which means I'm an expert in human behavior, those teenage years being just part of the developmental process. I know exactly what to do and say to assure that I have wonderful, happy, mentally healthy, well-adjusted, and successful children who glide through life glitch-free and openly share with me any of the little bumps they might encounter along the journey.

And now let me tell you about this little bridge I have for sale, it's a great bargain.

And let me tell you what they teach you about raising children in Medical School and Psychiatry Residency Training Programs. They don't teach you anything, at all, ever, about normal developmental adolescent behavior. Somewhere along the line I learned that babies develop a social smile between 5 and 8 weeks of age and they should be fed whole milk until age 2. Either the information stopped there, or I blocked everything else out.

Pediatrics rotations in medical school take place on an inpatient medical unit. I saw children with leukemia, babies with failure to thrive, kids with acute abdomens, and inevitably half of morning rounds went like this: "Bed A suffered burns on her right arm when mom's coffee spilled on her, Bed B has burns on his left leg from dad's spilled tea...." I did learn that parents should be very careful about hot beverages, hot bath water, and space heaters (--there was a major burn unit in the hospital where I studied). We had lectures on diarrhea while we sat around a table eating cookies. Not once did anyone tell me that it's completely normal for formerly articulate, intelligent boys to suddenly stop speaking and merely grunt for years at a time. Nor was there a course that mentioned how it's impossible for the mother of a teenage girl to dress right...or even breathe right. Honestly, I thought my own mother--who handled my obnoxious teenage years with grace-- embarrassed me because she was embarrassing. It didn't occur to me until I had teenagers of my own that it had more to do with me than with her.

Three months on an inpatient child psychiatry unit, with shifts in the pediatric ER, didn't help. I met kids who were completely out of control, chronic runaways, children who'd been violent in their group homes. In the ER I saw suicidal teenagers and had no where to place them --try finding an inpatient bed for an uninsured suicidal teen who's parent says they've had it won't take them back. Not only did I not learn a thing about normal adolescent development, but I saw the worst case scenarios of children who'd had lives that were tragically devastated at young ages, already paragons of loss, chaos, and upheaval. It wasn't a setting filled with hope; it takes a lot for a child to end up in an inpatient unit in an inner city teaching hospital.

Okay, so teenagers, this is the thing I'm figuring out: It's a stage, it's its own distinct thing, and being a psychiatrist, I have this tendency to look at my teenager's behaviors and extrapolate them to adulthood. I'm just getting it that a lot of normal teenage behavior looks surprisingly like impending disaster. Nothing about being a doctor helps with this, most of what I've learned being a psychiatrist makes it hard to keep things in perspective, especially when living with a teenage boy.

I'm not much for How-To-Raise-'Em books. Mostly, I thought we were doing fine by gut, but lately I've decided we could use a little help. I bought some books, I even read them, and I thought I'd share my thoughts about these books with you.

This was my favorite:
Get Out of My Life...but first could you drive me and Cheryl to the mall?
by Anthony E. Wolf, PhD.

This book was laugh-out-loud funny with descriptions that resonated so strongly I was left to ask how this guy knew my kid.

"What happens is that teenage boys develop terminal lethargy. They seem to catch a lengthy case of sleeping sickness. They appear to do nothing. If the normal speed of human activity is one hundred rpm's, teenage boys seem to go at around six."


You mean that's normal??? Why didn't anyone tell me? What a relief! And the list continued. I won't say I agreed with every thing Dr. Wolf says-- he sounds more willing to tolerate certain behaviors than I would ever be, but overall this was a quick read and did more for cuing me into Why I Shouldn't worry, What I Can't Control, and Why I need to Let Go, more than psychiatry ever has. Relief: yes. Sadly, I'm left knowing that my children are pushing me away because they are growing up and doing all the things they should be doing, and while it's always been easy to rejoice in their milestones, these stages entail a bit of quiet grief as I come to terms with the fact that my children will never have the relationship they had with me when they were little.

I Wanna Be Sedated, edited by Faith Conlon and Gail Hudson, is a collection of 30 essays by professional writers all on parenting teenagers. Okay, I admit it, I bought the book because the title was irresistible and at the moment I was surfing for books about raising teenagers, I really did want to be sedated. Some of these stories were hysterical-- we had both our kids read "How To Lie To Your Parents" by David Carkeet. "Mom? Everything's Okay, but..." by Linda Rue Quinn was funny even though neither of my children have actually set any part of our house on fire. The stories varied: funny, poignant, sad, even boring, but for the most part it was a compelling read. There were no parenting tips, it really was just the sharing of stories, and a reminder that teenagers, while in many ways alike in their stages, differ greatly in how easy or hard they can be to raise and what kind of people they actually are. The honesty of the writers was brutal at moments, at many points I was simply thankful not to share their problems, at other points I felt I'd found a kindred spirit. I smiled at Stephen J. Lyon's essay, "Commuting With Rose." He writes, "Anyway, as a parent of a teenager, you are always off balance--grasping at straws, parenting books, or a bottle of Zoloft. So you ten to stay with any small success. Sociologist love to rattle off statistics about how many minutes per day fathers spend with their children, always discounting the power of silent communication and the value of mere presence, along with the all-important fatherly stare and raised eyebrows. And they rarely speak of how little or erratically a teenager wants to relate with any parent."


Finally, I looked at Staying Connected to Your Teenager by Michael Riera, Ph.D. This is a more conventional How-To book and I had a harder time staying with it. In the first chapter, he suggests trying to talk to your teenager after midnight, and for a while, I'd try to stay awake that long. I made smores one night with my son and he recited to me the Shakespeare he'd had to memorize for school--it was definitely worth staying awake for and not a conversation that ever would have been had at a more civilized hour. Otherwise, though, it felt like the author had all the answers and I think my challenge has been to make peace with the fact that there probably are no real answers.

My Three Shrinks Podcast 32: Doctor Anonymous on Depression Overdiagnosis

[31] . . . [32] . . . [33] . . . [All]

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Today's podcast features a guest, Doctor Anonymous, who joined us via Skype. DrA is a midwest US primary care physician who blogs about medicine and health care. We've been trying to get him on for a while, but call schedules and such just didn't align. We both had Skype set up, I added Call Recorder (which allows you to easily record both sides of the conversation, each on a different channel), and it went off without a hitch.
DrIzzy from Michigan added a complimentary iTunes review (thank you), but he commented on our sound levels, which we agree are sometimes subpar. He points out that, since we have made the podcasting "big time" (LOL), we should get us some grown-up sound equipment. Now we are using a single Snowball microphone with the high-gain patch (mentioned in Podcast #3), which is sometimes doesn't pick up Clink and Dinah as well. So, we are thinking about getting a mixer and some lapel condenser mics. Let us know if any of you have suggestions about this. I'd like to add a couple Google ads on the sidebar to help pay for it; Dinah is equivocal. Let us know what you think. (Oh, the bird in the background is Monkey, my parakeet.)

Oh, and I see that DrA has started a call-in show! Check out the first one here.
-Roy

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September 2, 2007: #32 Doctor Anonymous on Depression Overdiagnosis



Topics include:

• DrA on Skype (not a soundboard). Dinah relished the memory of Podcast #24. Check out DrA's blog, doctoranonymous.blogspot.com.
  
  
• Is Depression Overdiagnosed? We discuss two point-counterpoint pieces in the August 18 2007 issue of BMJ (British Medical Journal). The YES piece is written by Gordon Parker, who believes there is a trend to turn "sadness" into a medical condition: "The ease of assigning a diagnosis of clinical depression, even of major depression, has rebounded on psychiatry, blunting clarification of causes and treatment specificity."
  
  The NO piece is written by Ian Hickie, who argues that despite the benefits of increased rates of diagnosis, many people with depression continue to go unrecognized, untreated, and impaired: "The increased rate of diagnosis has had other benefits, including reduced stigma, removal of structural impediments to employment and health benefits, increased access to life insurance, improved physical health outcomes, reduced secondary alcohol and drug misuse, and wider public understanding of the risks and benefits of coming forward for care."
  
  Find online comments on these articles at BMJ's website here.
  
  
• Further discussion about the symptoms of major depression, subsyndromal depression, dysthymia, substance abuse, the influence of the pharmaceutical industry, depression screening, access-to-care problems, inpatient bed capacity problems, per capita psychiatrists and psychologists, stigma about mental illness, primary care management of depression, emergency evaluations.
  
  
• We digress into hot McDonald's coffee, Twinkies, and chocolate.
  

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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.

Google Ads

On Sep 1, we started an experiment including a single Google ad block (usually 2 ads) on each page, primarily for the purpose of generating money to upgrade our podcasting equipment (which currently consists of three tin cans connected by string to my MacBook's USB port).

What we'd like to get is a mixing board and 4 quality condenser mics (~$500). Anyway, as of Sept 25 we've made $12.99 (wooo!). We've heard from one reader that an ad was served that went to an off-shore, drugs w/o a prescription site.

Google allows us to block ads from certain website, so if you find an an objectionable ad, please copy the url (right-click on the ad's link) and let us know the URL in a comment on this post. (Note, the url will look ugly, like http://pagead2.googlesyndication.com/pagead/iclk?sa=l&ai=BiNocrOP5RtarLZ6ca53TtcoCwqi0If7pm4ICwI23AcCaDBABGAEgiqPPBigCOABQqLXpyAJgyc6SiYikhBCyAR5wc3ljaGlhdHJpc3QtYmxvZy5ibG9nc3BvdC5jb226AQoxMjB4MjQwX2FzyAEB2gEmaHR0cDovL3BzeWNoaWF0cmlzdC1ibG9nLmJsb2dzcG90LmNvbS-oAwGwA5KVoAbIAwfoA4AF6AO1A-gDhgX1AwgAAAD1AwAAIAA&num=1&adurl=http://www.the_road-back.org/weight_-_loss.htm&client=ca-pub-1457668036852312&clkt=-1&nm=6
), but that's okay... just paste it in and we'll block it.)

Thanks!

My Patient, Myself

I saw this abstract and wanted to post it. Entitled Psychiatrist Attitudes toward Self-Treatment of Their Own Depression, it's a survey conducted of Michigan psychiatrists regarding their opinions toward self-prescribing. A survey of more than 500 Michigan psychiatrists showed that more than 40% would medicate themselves for mild to moderate depression and that 15% had actually done so in the past. Seven percent of psychiatrists said they would treat themselves for severe depression or depression involving suicidal ideation.

The AMA code of medical ethics states: "Physicians generally should not treat themselves or members of their immediate families...It would not always be inappropriate to undertake self-treatment or treatment of immediate family members. In emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available. In addition, while physicians should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems."

So why or when would a doctor consider treating himself? I don't know Michigan well, but I'd guess they probably have the same shortage of psychiatrists that other Midwestern states have. If you're a depressed psychiatrist you may be the only game in town. Maybe he'd be concerned about privacy and information-sharing among colleagues.

Or maybe the AMA would consider mild clinical depression to be a "short-term, minor problem" for which the self-treatment exception would apply. There are probably hundreds of physicians who at one time or another have written antibiotic prescriptions for themselves or for family members. I wonder if this also applies to prescribing for family pets? Should a psychiatrist prescribe Prozac for his obsessional cat? Thorazine for the nervous dog? A recent survey of neurologists showed that more than 90% agree that it would be appropriate to self-prescribe for acute minor illnesses. Another survey of young Norwegian physicians found that 90% had self-prescribed in the past year.

Don't ask me what Michigan surgeons would do...

Lecturing Shrinks

The Girl with the Blue Stethoscope has a post today (Why Is It So?) about how psychiatrists are the most interesting lecturers. She has great tastes, huh?

...I have noticed that psychiatrists as a group tend to give the most interesting and engaging lectures of all. Their voices are very natural and conversational in tone even as they lecture on academic topics, their communication skills are excellent, they look relaxed, and of course, they tend to have fantastic (yet anonymous) anecdotes.

I have noticed that medical students as a group tend to have the most insightful blog posts :-)

Grand Rounds @ Rickety Contrivances of Doing Good

Check out this week's Grand Rounds at Rickety Contrivances. It has a great spin to it:

This week's theme is Narrative Medicine. Pioneered by Rita Charon, an internist and professor at Columbia's College of Physicians and Surgeons, Narrative Medicine trains doctors and other caregivers to use careful listening and reflective writing to forge deeper connections with their patients, resulting in better care.

Charon describes three essential components of narrative medicine:

Attention: Listening carefully to patients, which includes remaining sensitive to what they may not be saying, gives the caregiver potentially valuable information and also makes the patient feel more cared for.

Representation: Using writing to reflect on patient interactions helps caregivers understand both their own feelings and those of their patients more deeply.

Affiliation: The process of attending carefully to patients and reflecting on patient stories ultimately makes caregivers stronger and more passionate patient advocates, because they've become more invested in their patients' care.

Don't Shrink Me

I was surfing the NY Times website and came across this article by Ronald Pies, a psychiatrist in the Boston area. Dr. Pies talks about a wonderful nurse he worked with in the psychiatric emergency room and his surprise when he walked on to the inpatient one morning to find this same wonderful nurse, now admitted as a patient with a severe major depression. Dr. Pies talks about wanting to save his colleague, and recounts how over the course of an 8-week admission, the patient's symptoms didn't respond to two different anti-depressants. He later runs into the patient, now cured of his atypical depression by an outpatient doc who recognized his atypical symptoms and more appropriately treated the patient with an MAOI (an older type of anti-depressant). Dr. Pies laments that he missed the diagnosis because the patient was a VIP of sorts, that he didn't get approached in the same way, with the same freshness and thoroughness, that a stranger would be, and he refers to Jerome Kroopman's book, How Doctors Think, as a reference for the celebrities-get-worse-care phenomenon.

We've talked about these issues here at Shrink Rap, asking whether docs as patients fare worse, and we even discussed a New Yorker article by Dr. Kroopman a few months ago. Here at Shrink Rap, we do it all.

I thought: I should write a blog post about this NYTimes piece. There's a lot to write about-- we could talk about Atypical Depression, missing diagnoses, the use of MAOIs in treatment today, treating people we know. Oh but it's August, I'm feeling lazy, I let it go. And then today, I was reading Clinical Psychiatry News, kind of psychiatry's version of a tabloid, and I saw a letter by the same Dr. Pies. He wrote to discuss how the term "Shrink" is demeaning, how we shouldn't use it. This, of course, inspired me to write this post, I'm still not sure what it's about.

There are some words that feel very powerful, some that squeeze me. Shrink isn't one of them (obviously). I don't generally refer to myself as a shrink--- except in Shrink Rap posts where it flows out pretty easily-- but when others do, I don't cringe. If it's supposed to be a derogatory term, demeaning, hurtful or vengeful, laden with stigma and rife with belittlement of my chosen profession, none of that has jelled in my heart. The term evokes nothing in me, it's not what I feel when I hear people utter racial or religious slurs. Should it be? Did I miss something big? I know Roy isn't nuts about the term "shrink." ClinkShrink, I'm guessing, has incorporated the word as part of her internalized identity.

I don't know Dr. Pies. I wonder if he'd like Shrink Rap, of if he'd just cringe at the title, shun the three psychiatrists who use a derogatory term so lightly, ducks and all. Gosh, are we just a bunch of quacks?

The New Man In Charge

Dinah sent me this link to a New York Times article about Robert Sillen, a former hospital administrator appointed to reform the California prison medical system. I know FooFoo5 has opinions about medical care in California prisons so I defer to his experiences there. I'm just here to think about change and how this is accomplished.

The Times article makes a point of highlighting Mr. Sillen's brash, at times profane, change-at-all-costs political incorrectness. As a Federally appointed health care receiver he has been put in charge of recreating the correctional health care system and he has threatened to break the bank to do it. Right off the top of my head, I have several thoughts about this.

My first thought is that I think I would like this guy. A straight-shooting administrator---even a profane one---would be a relief from the polished political bureaucracy that grinds ever-so-slowly and ineffectively. If he can get things accomplished by being that way, more power to him.

My second thought is that he probably won't last very long. Bureaucracy punishes efficiency, particularly when it's carried out without proper obeisance to the powers-that-be.

My third thought was triggered by this passage: "Mr. Sillen, whose $500,000 annual salary puts him among California’s highest paid public officials, said he had never visited a prison or thought much about the penal system until a recruiter called last year to persuade him to accept what the recruiter called a “mission impossible."

Oy. Uffda.

The man charged with reforming correctional health care has never been inside a prison. When he visited a penitentiary he was surprised to find "no sinks, no phones, no faxes, no way to communicate, no nothing". What? No phone? I'm shocked! Shocked, I tell you! As they used to say in the old Lost In Space show: "Danger, Will Robinson!" He is not a clinician, nor does he have correctional experience. Does anyone besides me think this is a bit odd? What were the Feds smoking? I hope he has clinical and correctional advisors he will listen to.

On the positive side, he's stating the obvious that everyone in free society needs to hear. He criticizes "tough on crime" policies that don't take into consideration the demand for health care services that these policies require. On the correctional administrative side, he criticizes prison officials who build new facilities without regard for treatment infrastructure. These are obvious things that need to be said loudly and repeatedly so no one forgets.

I wish him well.

I Need My Meds!!

It's August and I'm back in town. Psychiatrists are notorious for taking vacation in August, I hear they all go to Wellfleet. Sounds wonderful.

Back in Baltimore, I'm covering for a vacationing psychiatrist who often covers for me. We've cross-covered for years and I've handled just a few emergency calls, but quite a number of prescription refills.

They never teach you in medical school or residency the exact right way to handle writing prescriptions for patients of other docs while they're away, or if they did, I missed that class. People do what they're comfortable with and I have my own standards. If you'll remember from my post Covering Your... some time back, another doc (not the one I usually cross-cover with) once insisted on meeting with one of my patients before he would okay a refill on a medication-- it was a med she'd been on for years, and not a controlled substance, so I was surprised that he didn't just authorize the refill over the phone.

So it's August, and my phone rang today with a request: I'm Dr. Wellfleet's patient and he's away and I'll be out of meds tomorrow. Why, I think, does the patient wait until the day before they're out of medicine? This happens all the time. Now the confounding factor here is that Dr. Wellfleet prescribes controlled medications more often then I do, specifically stimulants to treat Attention Deficit Disorder, sometimes in high doses, that I don't generally feel comfortable prescribing. These medications, in Maryland, can not be refilled or phoned in and the prescription can't be faxed. The patient must present a hard copy of the script each month to the pharmacist, so the patient's request the day before creates a number of issues for me: first I'm left to decide if I'll prescribe a controlled substance to a patient I haven't examined, and I have to ask if it's even reasonable to insist on examining a patient I'm cross-covering for particularly on a day's notice when I likely don't have an appointment --or if I do, what if the patient can't meet at the precise time I can? Or what if I meet with the patient and don't agree with the diagnosis and treatment-- is it reasonable to take a patient off a medication their regular doc, a well-respected and experienced psychiatrist, is prescribing anyway, and if not, then what's the point of meeting with them anyway? And what about the time I got a call from a patient out-of-state requesting a medication I would never feel comfortable prescribing-- she insisted Dr. Wellfleet's been prescribing it for years, the pharmacy verified this, the patient was hours away, and if I refused, the patient would go into a withdrawal which would require a hospitalization to manage. Oy.

Mostly, I deal with cross-coverage medication requests by phoning the pharmacy and verifying that the patient has actually been maintained on the medication by the regular shrink, that the medicine really does need to be refilled, that everything is kosher. If I can phone it in, I do. If it's a controlled substance, I authorize enough to hold the patient until their regular doc returns. If it needs a hard copy prescription, I do my best. If the patient calls on a day's notice, and I'm not scheduled to be in the office that day, they're out of luck --you can skip doses of stimulants without getting sick. I suppose I feel a bit like the patient is turning their disorganization into my emergency and when I'm sitting on hold with the pharmacy, negotiating times the patient can pick up the script, or feeling a little uneasy about writing for a specific med, I'm left to wonder if there isn't either a more efficient or more sanctioned way of doing this uncomfortable task without causing people to simply go without their meds, offending the doc I'm covering for, letting the patients risk relapse, or insisting on seeing the patients,with all the muck of what if I don't agree with the treatment and how will I squeeze them into my schedule.

So what do other shrinks do?

And Blue is the favorite color of half of Shrink Rap readers.

Molecular Psychiatry: Schizophrenia Mouse Model

Here's another interesting knockout mouse model for schizophrenia. This was in the July 31 issue of Molecular Psychiatry, "Phospholipase C-1 knockout mice exhibit endophenotypes modeling schizophrenia which are rescued by environmental enrichment and clozapine administration," by McOmish et al., in Australia.

"Phospholipase C-1 (PLC-1) is a rate-limiting enzyme implicated in postnatal-cortical development and neuronal plasticity. PLC-1 transduces intracellular signals from specific muscarinic, glutamate and serotonin receptors, all of which have been implicated in the pathogenesis of schizophrenia. Here, we present data to show that PLC-1 knockout mice display locomotor hyperactivity, sensorimotor gating deficits as well as cognitive impairment. These changes in behavior are regarded as endophenotypes homologous to schizophrenia-like symptoms in rodents. Importantly, the locomotor hyperactivity and sensorimotor gating deficits in PLC-1 knockout mice are subject to beneficial modulation by environmental enrichment. Furthermore, clozapine but not haloperidol (atypical and typical antipsychotics, respectively) rescues the sensorimotor gating deficit in these animals, suggesting selective predictive validity. We also demonstrate a relationship between the beneficial effects of environmental enrichment and levels of M1/M4 muscarinic acetylcholine receptor binding in the neocortex and hippocampus. Thus we have demonstrated a novel mouse model, displaying disruption of multiple postsynaptic signals implicated in the pathogenesis of schizophrenia, a relevant behavioral phenotype and associated gene–environment interactions."

PLC-1 is one of those proteins involved in processing the signal after the receptor is activated. Think of the ignition in your car. If the key is the neurotransmitter, like serotonin (or medication, like Prozac) and the lock (or keyhole) is the receptor, then PLC-1 is one of the wires that connects the lock on the steering column to the starter, which gets the engine going. We are all so used to thinking that what is important is the action at the receptor, but it is easy to forget that there is this whole other layer of machinery that gets engaged once the receptor is activated.

These so-called second messenger systems use a cascade of Rube Goldberg connectors to make things happen. Just like a genetic error can cause a receptor to malfunction, so can errors in this second messenger cascade.

This particular enzyme is involved in the growth and connectivity of brain cells. The researchers show that mice who are engineered to not produce PLC-ß-1 develop cognitive problems which have similarities to those seen in humans with schizophrenia. Changes in the environment can minimize these problems, suggesting that this animal model could be used to test other treatments -- including medications that work very differently from what is out there now -- for potential use in this neurodevelopmental illness.

My Three Shrinks Podcast 31: Biteproof Gloves

[30] . . . [31] . . . [32] . . . [All]

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Here is the little "podette" I mentioned last time. The next podcast, which will come out in the next day or so, features a special guest, Doctor Anonymous.



August 20, 2007: #31 Biteproof Gloves



Topics include:

• Q&A: from Midwife with a Knife: Short version: How would you manage an agitated, aggressive patient in your OB/GYN office?
  
  [Okay, here's the long version: Let's say I have this patient who's clearly distressed and obviously psychotic (if I can tell, it's pretty obvious) who's caretaker reports that they're seriously considering hurting themselves or others, clearly the patient needs to be sent to the psych ed/crisis center/whatever hospital equivalent for evaluation by an actual mental health provider... So, after the caretaker says to us, "I'm worried about taking her back to the group home, I'm think she's planning to hurt someone there.", and I talk with the patient who says something to the effect of, "I know that woman's planning to take my baby, and I'm going to hurt her before she gets the chance." I make the decision that she needs to be emergently evaluated. I try to talk her into going voluntarily (mostly by saying things like, "You seem pretty upset, I think it might help if you went and talked with the doctors downstairs", she refuses, and security is called to escort her down to the psych ed. Eventually, (I think triggered by the stress of that situation and the chaos of a busy clinic and the security officer's arrival), and in an attempt to leave the room (I happened to be sitting between her and the door), she kind of half tackled/half grabbed/half pushed me (Maybe to push me out of the way? I think she was just trying to leave. I don't think she was really trying to hurt me), the security officer grabbed her, she bit him (although he was wearing biteproof gloves) and she eventually was taken to psych. My question for you guys is, how do you psychiatrists recommend those sorts of situations be handled?
  
  So, we answer the question in the podcast. We also speculate about "bite-proof gloves."
  

Oh, and if you want to see a funny but very strange rendition of Zappa's Peaches and Regalia -- with a man using his ungloved but cupped hands as a musical instrument -- then do check out this YouTube video (turn down your volume first). I could not stop laughing.

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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.

It's Fun Until Someone Gets Hurt, Then It's Hilarious

This isn't a post about psychiatry. Pretend you don't know I'm a shrink. This is a post by an old person ranting, most specifically by the mother of teenagers, ranting.

It's Fun Until Someone Gets Hurt, Then It's Hilarious

I saw that on a T-shirt recently, and actually the T-shirt was being worn by someone my age, the father of two teenagers. It pictured a skier stick figure, upside down, and I cringed-- why is it fun to watch someone get hurt? Why would someone make a T-shirt advertising that, and why would another someone buy it and wear it in public? I don't get it.



I grew up in a world where it became very important to be sensitive to others, to be conscious of what one says in terms of race, religion, nationality, gender. Words are important and if you utter the wrong ones, even innocently, you can be minced. I grew up in the North, post-Civil Rights, and attended integrated public schools and gender-balanced institutions of higher learning. Obscenities were bleeped on TV and Clarence Thomas was on trial for sexual harassment. My world started in a sensitive place, it's grown even more so.



Suddenly, it feels like the pendulum has swung the other direction-- a complete reaction to interpersonal sensitivity. I've entered (somewhat involuntarily, but hey, I had them) the world of teenagers. Words that have always been so powerful and negative, well, suddenly they're terms of endearment. I borrowed an iPod the other day to jog with-- Golly Gee, Wally-- 1800 downloaded songs and they each consisted of the same three obscene words chanted over and over. All I can figure is this culture irreverence-- perhaps best personified by the ugly and inept words of Don Imus-- is a cultural backlash to a world where being politically correct has become so important, so hammered into us.



I read an article not long ago in the Baltimore Sun-- it was about an entrepreneurial young man whose Internet T-shirt business had taken off. What an industrious young man. I went to the website, curious. Here's one of the shirts he sells:

You get the idea.

Mostly, the teenage world seems to have some feel for when and where-- they utter the unthinkable words and phrases amongst themselves, they understand (or so I'm told) their own code-- they keep this world hidden, and well they should. I may be wrong, but the rules all seem fuzzy as to who can say what to whom, where and when. Probably, and I may just be old, Mr. Brady, it would be fine if T shirts didn't announce the insensitivity of the wearer.

The good news is that I found some Led Zeppelin tunes on the iPod. There's still hope.