Failed Heroism and the Shrink Rappers Pursue the Perfect Pizza

The Shrink Rappers have a new quest: to find the best pizza in Baltimore. Don't get me wrong, we still like ducks, but this is a culinary adventure.

So, Victor started it: he read about Matthew's Pizza in a Laura Lippman novel. Clinkshrink couldn't wait, she went without us. Roy says Carmine's is the best, and he's currently in Las Vegas trying to win the big bucks to pay for new recording equipment for our My Three Shrinks podcast. We started without him.

So it was a bit of an adventure getting to Matthew's. First there was the parking space issue, and then, as we walked the few blocks to the restaurant, we came across what appeared to be a dead body in front of a church. People sleep on sidewalks on church steps
all the time, this gentleman was in the middle of the sidewalk. Clink asked him if he was okay, and as he raised his head, there was a small pool of blood on the concrete. We called for an ambulance, and Clink asked the man a few questions, she had him move all his extremities, he seemed coherent, and Clink was relieved that he didn't seem to be one of her patient/inmates. He said he'd been jumped and someone tried to take his money. The blood was coming from a small laceration on his forehead and it seemed to have stopped bleeding. I called his wife.

"I'm looking for..." oops. Excuse me, sir, what's your name?
"I'm looking for John's wife (not his real name)."
"I'm his EX-WIFE." I told her we'd found him, that he seemed to be okay, that the paramedics were here wrapping his wound, that he'd been mugged and hit his head and was going to be taken to a hospital.
"He had too much to drink," she said. And judging by the smell of things, she may have been right.

My second attempt to be a hero this weekend happened when I was walking with Max. We were far from home on a quiet road when we met a wet, slightly bedraggled little dog standing in the middle of the street. I guess I think that when people or dogs actually belong somewhere, they move towards the curb. I would have assumed he lived there, but I looked at his tag and it gave an address that was miles away. Poor little thing. I tethered him onto Max's leash and walked around the block to a friend's house. Their kitchen door was open, so I walked in with two dogs in tow, and asked for a phone.

The tag identified the dog as Louis Vuitton Adams. This is his real name, I've decided that anyone who names their dog Loius Vuitton should expect to find their pet on someone's blog. That's the Adams' dog, I was told. Apparently his owners have divorced and the address on the tag is the ex-wife's address.

I thought I was rescuing a dog, instead I had stolen one.

So Matthew's Pizza was wonderful. When Roy comes back, we'll try Carmine's. If he's lost all his money, it's okay, ClinkShrink will treat. If you know of any great Pizza places you'd like to us to try, please write in. I'm up for a pizza project.

Oh, was this supposed to have something to do with psychiatry?

My Three Shrinks Podcast 35: Shrinks on Film

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Last week, we had our guest, Dr. Mark Komrad, join us and begin to discuss the portrayal of psychiatrists in the movies. Mark used to have a live, two-hour, coast-to-coast, nationally syndicated talk radio show, and is a regular guest on NPR. He is also the Ask-a-Doctor on the NAMI site, and also has a book coming out. Mark was a guest blogger back in July, when he posted on Ethics and Continuing Education for the Psychiatrist.
This week Mark continues to discuss how Hollywood likes to portray psychiatrists in film. You can find him at www.komrad.yourmd.com. (Unfortunately, Monkey the parakeet gets sidelined in this podcast.)

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October 5, 2007: #35 Shrinks on Film


Topics include:

• Leona Helmsley's dog, Testamentary capacity, and Psychological Autopsies. ClinkShrink discusses how one starts to address the question of competency to being able to make the decsion to leave $12 million to one's dog. Bounty and one's natural heirs.
  
  
• Irv Schneider's 3 Psychiatric Archetypes: Doctors Dippy, Darling & Dangerous. These are the three categories of psychiatrists most frequently played in the movies and television.
  
  -Dr. Dippy: Bob Newhart Show; What About Bob? (Richard Dreyfuss); High Anxiety (Mel Brooks); Analyze This (Billy Crystal)
  
  -Dr. Darling: Equus (Richard Burton); The Sopranos (Dr. Melfi); Sixth Sense (Bruce Willis); Good Will Hunting (Robin Williams); Prince of Tides (Barbra Streisand); Ordinary People (Judd Hirsch); K-PAX (Jeff Bridges)
  
  -Dr. Dangerous: Silence of the Lambs (Anthony Hopkins); Terminator 2: Judgment Day (Dr. Silberman); Dressed to Kill (Michael Caine); Beauty and the Beast (Belle's father)
  
  See My Patient, Myself. How we must "neutralize" the negative images of psychiatrists in the media, "like your podcast." How the movie, Lovesick, affected the idea of psychiatrists falling in love with their patients.
  
  
  
• Psychiatric Services: Religion and Psychiatry. We have an interesting talk about the role that a physician's religious background may play in the likelihood of referring a patient with complicated grief to clergy versus a psychiatrist. See Roy's upcoming post on Religion and Psychiatry for more info. Briefly:
  
  -Psychiatric physicians were more likely to be Jewish or non-religious than nonpsychiatric physicians.
  
  -Protestant physicians were twice as likely as other physicians to refer the example patient to clergy rather than a psychiatrist.
  
  
  
• Washington Post on Virginia Tech: Roy briefly mentions his recent post on the final report on the Virginia Tech tragedy and the potential impacts on privacy of health care information, willingness of college students to get help, and liability. Dinah suggests readers go back to look at our prior posts about college mental health, Suicidal Students and Let's Talk About Suicide. This also led to a discussion about outpatient commitment.
  
  
  
• Correction: Dinah corrects her reference in Podcast 34 to Reign Over Me. The movie she was actually discussing was The Departed.
  

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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.

Virginia Tech Shooting: Final Report

The final report on the investigation of the Virginia Tech tragedy was released in September (see also Washington Post story).

Some of the Recommendations:

11 recommendations by the panel (go to past 2 pages of the pdf), including:

• short- and long-term counseling to affected individuals
• crisis-management training for colleges

7 recommendations about changing privacy laws (last 3 pages), including:

• exempting university clinics from FERPA, so medical treatment info can be released without student's consent;
• adding good faith, safe harbor provisions for certain disclosures;
• reducing privacy rights for "troubled students";
• deeming law enforcement and medical personnel to be "school officials", which permits greater access to students' records;
• consider making all commitment hearing results public information

12 recommendations [.pdf] about changes in college mental health services (beg on pg 53), including:

• system of linking "troubled students" to counseling services on and off campus;
• adequate, culturally-competent community MH services for children and adolescents;
• requirements that professors and resident hall staff report all "aberrant" behaviors to the dean;
• repeated incidents of aberrant behavior be reported to the counseling center and to parents;
• counseling center report all students in court-ordered treatment to the threat assessment team;
• expansion of outpatient MH services statewide to meet community needs

14 recommendations [.pdf, same as above link] for changes (pg 60) in Virginia laws, including:

• extension of time period for temporary detention on an Emergency Petition (EP); allowing ER docs to do EPs (weird, they can do them in Maryland);
• lowering the "imminent danger" standard;
• increase the # of crisis stabilization beds to reduce waiting in ERs;
• assuring the "independent evaluator" has access to "necessary reports and collateral info" prior to the independent commitment eval;
• setting certain standards for the commitment hearings (ones I think Maryland already meets);
• reducing privacy rights for anyone going thru commitment proceedings;
• tightening up involuntary outpatient commitment procedures;
• "the sanction(s) to be imposed on the no-compliant [sic] person who does not pose an imminent danger to himself or others";
• requiring providers to report noncompliance with involuntary outpatient orders

Conscientious Nuns Less Likely to Get Alzheimer's Disease

First I got an email about this from Medscape. Then I saw it in the Wall Street Journal's Health Blog. Then I clicked through to the abstract from the Archives of General Psychiatry.


So there's this prospective study of Catholic clergy--priest, nuns, and brother-- called The Religious Orders Study at Rush University, where the participants have yearly physical and psychological exams and agree to donate their brains for autopsy at the appropriate time. Wow. The Religious Orders Study has been going since 1993 and is funded by the National Institute on Aging.

Okay, so Jacob Goldstein at the WSJ blog tells us:

A high conscientiousness score — which the authors describe as reflecting a “tendency to control impulses and be goal directed” — was associated with an 89% reduction in the risk of disease compared with a low score, even after accounting for age, sex and education.

By 'sex' I think he means gender.

At any rate, this study made me think of my dear friend ClinkShrink, pictured above, who a) is often mistaken for a nun and b) is very conscientious.

I'm hoping this bodes well for her brain. If not, I'll still be her friend.

Ain't It Romantic?

I have a nasty little secret to confess. Here it is:

I like opera.

Yes, it's true. I may listen to KMFDM, Pig, Nine Inch Nails and Rammstein while working out, but in my spare time I've been known to watch Tosca, Nabucco and Carmen. This weekend I saw Aida at the New York Metropolitan Opera.

This blog post was inspired by Act III, where the Egyptian general Radames meets his lover, the slave girl Aida, down by the Nile. He's betrothed to marry the Pharoah's daughter the next day, and Aida fears he's coming to tell her he'll never see her again. She stands by the riverside bemoaning the loss of her love, and declares that if she loses him she will throw herself into the river and drown her sorrows permanently.

This is standard opera fare---in the end the hero and heroine both end up dead---but the thing that intrigued me was a story that was told to me by the lawyer sitting next to me. Apparently he was at a performance of Macbeth in which an audience member jumped to his death from a balcony seat during intermission. After an extended intermission (the performance was also being broadcast) the show was ultimately cancelled while police investigated to determine if the death was a suicide or a murder. After a little bit of googling I quickly found the New York Times story about the incident here, as well as a bit about the man who died here.

Hearing about this man's death put the opera into a new light for me. It got me thinking about culture in general and about the romanticization (if that's a word) of suicide. From Anna Karenina and her train to Romeo and Juliet and their poison, we've got people "proving" their love by killing themselves. The wedding ring and the gun are inextricably juxtaposed in drama and in real life. When my patients talk about their girlfriends and I hear the phrase, "I love her to death," I cringe inwardly and want to blurt, "Please don't."

JCP: Family Intervention Overcomes Poop-out

Your taking an antidepressant for major depression, but after a year or two it seems to wear off; what some call SSRI Poop-out. A recent article in the Journal of Clinical Psychiatry finds that a family intervention approach to this problem is more effective than increasing the dose of the antidepressant.

Can anyone educate us about the "McMaster model"?


Family Intervention Approach to Loss of Clinical Effect During Long-Term Antidepressant Treatment: A Pilot Study

Background: The return of depressive symptoms during maintenance antidepressant treatment is a common phenomenon, but has attracted very limited research attention. The aims of this investigation were to explore the feasibility of a family intervention approach to loss of clinical effect during long-term antidepressant therapy and to compare this approach with dose increase.

Method: Twenty outpatients with recurrent major depressive disorder (diagnosed using Research Diagnostic Criteria, i.e., patients were at their third or greater episode of major depressive disorder, with the immediately preceding episode being no more than 2.5 years before the onset of the episode which led to antidepressant treatment) who lived with a partner and relapsed while taking antidepressant drugs were randomly assigned to (1) family intervention approach according to the McMaster Model and maintenance of the antidepressant drug at the same dosage or (2) dose increase and clinical management. A 1-year follow-up was performed. The study was conducted from January 2002 to December 2004.

Results: Seven of 10 patients responded to an increased dosage; all but 1 relapsed again on that dosage during follow-up. Seven of 10 patients responded to family intervention, but only 1 relapsed during follow-up. The difference in relapse was significant (p < .05). Conclusions: The data suggest that application of a family intervention approach is feasible when there is a loss of clinical effect during long-term antidepressant treatment, and this approach may carry long-term benefits. The results need to be confirmed by large-scale controlled studies but should alert the physician to explore the psychosocial correlates of loss of clinical effect.

(J Clin Psychiatry 2007;68:1348-1351)

My Three Shrinks Podcast 34: Guest Mark Komrad, MD

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This week we have a special guest, Dr. Mark Komrad, who is an old hat at discussing psychiatric issues on broadcast media. Mark had a live, two-hour, coast-to-coast, nationally syndicated talk radio show for about 5 years. He also had a regular gig on Channel 2 with Rudy Miller, and continues to be a regular guest on NPR. Mark is the Ask-a-Doctor on the NAMI site, and also has a book coming out. Mark was a guest blogger in July, when he posted on Ethics and Continuing Education for the Psychiatrist. (And Monkey the parakeet joins in.)

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September 26, 2007: #34 Guest Mark Komrad, MD


Topics include:

• Prison Tattoo Database. Clink informs us about Maryland's tattoo database.
  Dr. Komrad talks about Match.com's inclusion of tattoos in their matching database. We also talk a bit about the psychology of getting tattoos, in general.
  
  
  
  
• Q&A: I am a second-year medical student in Canada who is considering psychiatry. I have a few questions that hopefully you haven't already addressed elsewhere.
  
  Firstly, do you get many negative responses from other medical professionals and the general public for being psychiatrists. If so, how do you deal with it?
  
  Secondly, can you discuss some of the differences you know of in practicing psychiatry in Canada versus the US?
  
  
• Dr. Komrad discusses how he got into Psychiatry, and the images of Psychiatrists in the movies and in Hollywood. (Mentions Irving Goffman here.) Mark points out that only 3% of Americans have even been to a psychiatrist, and so most people learn about what Psychiatry is about from movies. Movies and shows discussed include The Sopranos, Dark Shadows, Beauty and the Beast, Prince of Tides... more on Podcast #35.
  
  
• Check out NAMI's Ask-the-Doctor column that Mark writes, also his website at komradmd.com.
  
  
• [Edit] Correction: Somewhere on the podcast, Dinah discusses a movie she incorrectly refers to as Reign Over Me. She meant to say The Departed.
  
  

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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.

The Co$t of Being Depressed

Okay, I've truly lost it. I've just spent the last half hour on the phone calling a couple of pharmacies to find out the cost of antidepressants, all for Shrink Rap. You see, as a doctor, I've never learned what this stuff costs. I know vaguely that the older stuff is cheap, and the latest greatest is expensive, sometimes really expensive. I actually started my research yesterday. I thought I'd compare the prices at a local independent boutique pharmacist in a ritzy neighborhood where home delivery is offered, to a chain, to Walmart or Sams Club with the assumption that Walmart would be the cheapest--though really, I'm not sure of this. My quest was limited, however. By the time I really sat down to do this, it was so late I was limited to 24-hour pharmacies, so no Walmart in the comparison.

With my gratitude to the pharmacists who humored me, here's what I found.

The local independent pharmacy informed me that "our system doesn't allow us to look it up without a prescription." Huh? I asked again several times, they couldn't tell me what a medication cost. Okay....

CVS-- a large chain store-- I got a pleasant sales person on the phone.
Similarly at Walgreens. Pharmacists are generally nice people, I've found.
So all prices are for 30 pills, I aimed at the usual antidepressant doses. A little bit of confusion around Elavil (amitryptiline), one of the older tricyclic antidepressants which I just about never use, but it's cheap. I asked about a 100mg dose and CVS told me it came as 75 mg while Walgreens said they had it as 100mg. I only asked for a few prices at Walgreens, mostly to see if there was variation (there was). Zoloft, Lexapro, and Trazodone are scored pills, so if you take half the listed dose, this will last you two months. Many people, however, are on 200 mg of zoloft, and since the largest pill is the 100mg tablet, double the price for high doses. These are the cash prices, in US dollars, and I called pharmacies in Maryland. I tried to set this up as a table spreadsheet, but blogger ate that format.

Paxil, 20 mg...................... 125.99
generic Paxil 20 mg............ 48.95
generic Prozac, 20 mg ........19.19 .............29.99 (Walgreens)
Zoloft, 100 mg ....................140.99
generic Zoloft, 100mg ......... 45.19
Celexa, 40mg .......................122.99
generic Celexa, 40mg............ 33.69
Cymbalta, 60mg .................. 149.99........... 142.99 (Walgreens)
Nortryptiltine, generic, 75mg.. 31.69
Lexapro, 20 mg ..................... 106.99......... 105.99( Walgreens)
Elavil, 75mg ............................53.59
generic Elavil, 75mg................ 10.99,,,,,,,,,,, 12.39 (walgreens)
Trazodone, 150mg ,,,,,,,,,,,,,,,,,,, 23.19
Wellbutrin XL, 300mg............ 215.99
generic Wellbutrin XL, 300mg... 149.99....... 139.99 (Walgreens)

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[from Roy]
Don't forget about Walmart's $4 list. You can buy 30 pills of any of these for $4, whether you have insurance or not. In the hospital, we frequently choose meds for uninsured pts based on this list (eg, Prozac 20 mg = $4/mo. Elavil, Paxil, Trazodone and Doxepin are other choices for antidepressants.)

How to Select an Antidepressant: Part 2

Dinah posted about How Psychiatrists Select Antidepressants, which was a very thoughtful and concise description of the factors we take into consideration. Supremacy Claus commented on Dinah's pragmatic, plain-speaking distillation (talk about plain-speaking pragmatism, check out this legal eagle's excellent blog). Dr Smak (another great blog... she and Dinah should go shoe-shopping together) was surprised to find no mysterious revelations, and "The" Shrink (a great new psychiatrist blog... welcome!) felt doctor preference was a missing element.

I started a comment, but it got so long and non-plain-speaking (sorry, S. Claus) that I moved it here.

Shrink, not so sure about the physician preference part (or maybe I am atypical... ha). I don't have a "favorite" or fall back antidepressant, as I find that when I apply Dinah's list (which is quite comprehensive and a good list), I am usually left with one or a couple drugs, and can still find a reason to pick one over the other (eg, cost). I feel I am quite familiar with the zillions (ok, maybe it's only 15 or 20) and ready to pick whichever seems best.

I do think Dinah's #4, 5, and 6 should be expanded on, and #4 should be split into 2 separate sections (I'm a splitter)... #4a being Other Medical Issues (eg, Seizure -x-> Wellbutrin; Psoriasis -x-> Lithium; Hypertension -x-> Effexor; etc) and #4b being Drug Interactions.

Drug Interactions is a whole 'nother post, and is a BIG factor for me when prescribing. Many of my pts are on multiple meds, so it becomes really important to think about this. Prozac and Paxil, for example, are famous for 2D6 interactions, so I avoid it when folks are on drugs which are solely metabolized by that enzyme. Luvox is a great hs antidepressant, but will muck with 1A2-metabolized drugs. Serzone and 3A4 drugs (though, haven't seen Serzone in years now... too bad, was a great drug to have around, esp if you knew how to use it... great for blocking SSRI-induced sexual side effects).

#5: Target Sx - When I think thru these, I think in terms of receptors (may be a tomato-tomahto thing here). I hear "no appetite" and think "I want histamine antagonism"; I hear "can't concentrate" and think "dopamine agonism"; I hear "no energy" and think "norepinephrine".

#6: Side Effect Profile - This is the one I spend the most time on with a pt. For any given side effect that is either desireable (sleepy, energizing, stimulates appetite, reduces appetite, etc) or undesireable (weight gain, wt loss, sexual, rash, seizure, nausea, etc), I have a pecking order in my head of drugs and their propensity to cause -- or not cause -- the particular side effect (other term is "adverse reaction", though they are only "adverse" when undesireable). The above 3 sections are where a better understanding of psychopharmacogenetics would come in handy.

The above may be where Dr Smak noted the perceived "secret way" in which shrinks pick 'em. What may be different in the way in which psychiatrists and PCPs select antidepressants is just in the way these thought processes get all merged together, or maybe thought about in an explicit way (my receptor-tomahto approach) or an implicit or nonverbal way (Dinah's best guess-tomato approach).

This "gut feeling" about which drug to use is merely the end result of a massive probability calculation which is automatically performed in the brain, based on all the above input about which side effects or target symptoms should take precedence for that specific pt, which drugs are more or less likely to deliver them based on receptor and metabolic profiles and based on literature and personal experience, in addition to the other factors like likelihood for compliance and affordability, all boiled down to a single "I think you should try Effexor". Much of that calculation is not conscious, and I think Dinah belies the complexity under the surface by simply (but honestly) stating "my best guess".

How A Shrink Picks An Anti-Depressant

[Part Two of this post is here]

Midwife With A Knife wants to know how a psychiatrist chooses a medication for an SSRI-naive patient. Wow, I'd already started that post when she asked.

So a patient comes for treatment. His symptoms meet criteria for Major Depression, no question here, and he wants medication to help his condition. This is his first visit to see me.

Prozac Paxil Zoloft Lexapro Celexa Luvox Effexor Cymbalta Lamictal
Wellbutrin Remeron Serzone Pamelor Elavil Nardil Parnate Emsam Trazodone

I probably missed a few.

So how does a shrink decide what medicine to begin?

1) Past history of response. If the patient says, Oh, yeah, six years ago I felt this way, I took Paxil for six months and that helped a lot and I didn't have any side effects, then Paxil it is.
The path changes if the story is that the medication didn't work or had side effects.

2) Family history of response. This is the patient's first episode, but mom swears by Wellbutrin, it's helped her when nothing else would. This would be a good first choice.

3) Patient preference. He's here because his best friend took Celexa and became a new and wonderful person. I have no idea what friend's diagnosis is or why Celexa was chosen for friend, but if there isn't a contra-indication, then I might as well honor a patient's wishes and there's some power to believing something will help. Similarly, if patient reports that Celexa caused best friend to commit outrageous acts of horror and he wants anything but Celexa, I pick something else.

4) Other Medical Issues. I don't start with meds that interact with what the patient's already on. I don't pick meds that might exacerbate an existing medical condition. Wellbutrin is contra-indicated in patients with seizure disorders, eating disorders, or a history of CNS lesions, so I don't start with it in these patients. I save the risky stuff for after we've been at it a while, and then only with a fair amount of discussion about possible risks compared to possible benefits.

5) My Best Guess at What Will Help the Target Symptoms. Patient is tired and unmotivated...Wellbutrin is reportedly a bit energizing, so maybe that's what I use. Patient also has a lot of OCD symptoms, I might go with an SSRI. If someone has a concurrent pain syndrome, Cymbalta or a TCA might be my first choice.

6) My Best Guess at the Side Effect Profile, for better or for worse. Really, this is a guess. I actually hate this issue because patients often worry about side effects they never get, but okay, if someone is agitated, I might start something I think of as being more calming. If someone says they'll die if they gain a single pound, I pick something more weight neutral.

7) The Patient's Financial Concerns and What I have Samples of. This is only a consideration if the patient is uninsured and paying cash for the meds, but this is not a trivial thing. After that, I move to What's Cheapest that will work and won't cause intolerable side effects. If the patient has been on something and had good success, then loses their insurance, I might try something cheaper in the same class of meds, but I wouldn't recommend a switch from say a working SSRI to a cheap Tricylic-- it's not worth the risk.

Can I say a word about Weight Gain as a side effect? Some patients refuse any medication that's been associated with this. But clearly, and I'm probably repeating myself at this point, there are people who don't gain weight on medicines that are said to cause weight gain, just like there are people who don't get better with anti-anythings. People respond to meds differently. My suggestion to those who are concerned they'll gain weight-- if there's some reason to believe a medicine might help, it may be worth a try. Buy a scale. Get weighed before starting the medication. Get weighed every 2-3 days after starting it. If you gain 5 pounds (1 or 2 or 3 can be variations in fluid retention or scale flakiness), Then it's worth worrying about weight gain and addressing whether it makes sense to continue.

We've been at this blog so long, I've lost track of what I've said already, what I've thought about saying, what I want to say.

What's Your Favorite SSRI?

I like polls....something about asking questions and thinking about the answers. It started on our sidebar with Who Are You? Then, What Do You Want To Read About on Shrink Rap? Then, for lack of anything more creative to ask, What's Your Favorite Color? One day it seemed like the question should be more psychiatric to fit the Shrink Rap theme, so with little thought, I changed it to What's Your Favorite SSRI? Only I suddenly found myself tracking the answers. I didn't ask, purposely, things that might give the question some perspective: like what are you basing your answer on-- the comparison of results of your 732 patients, all of whom have been on every SSRI, or your own experience taking them--which may or may not include a comparative factor. I see lots of people who better on the first SSRI they take, swear by that med, and there's no reason to go further. Some patients are clear that one works for them while another doesn't. Tried my wife's Zoloft and it just isn't Prozac (the names have been changed to protect the innocent).

SSRI's wandered into the psychiatric scene at the start of my training, so I've watched the evolution. First let me tell you my totally random, not-particularly scientific but observational thoughts on each of the SSRI's on the poll. Then you can tell me what you think in the comment section (or Roy & Clink can hi-jack the post and add their profound thoughts if they so wish).
Prozac: It wasn't around when I was a med student, so I saw glimpses of the world before and after. This medicine clearly changed some people's lives in dramatic ways. It's easy to use-- at first the smallest pill was 20 mg and that was the therapeutic dose (though soon we were zooming it up for OCD patients). Fewer side effects than TCAs, not all that hassle with EKGs and blood levels and therapeutic windows and pretty dramatic toxicities. I worked on the inpatient units during it's earliest days where sexual side effects weren't such a big deal. Not that they weren't a big deal, but the patients would get better and go home and then they'd be a big deal, but the outpatient docs were the ones to hear about it. For the people they worked for, Prozac was a good medicine, and it opened up some people's lives.

Zoloft: It's selling point was a shorter half life, fewer side effects, less agitation, and if you don't tolerate it, it's out of your system sooner than Prozac. At first, I didn't think it worked as well-- it didn't seem to have the life-changing benefits of Zoloft. I started asking other people I worked with: Have you seen patients have great responses with Zoloft? This was an informal poll. A few said yes. A few said, "I've seen people have great responses with Prozac." It became a kind of self-fulfilling prophesy for a bit there-- I used Prozac more so of course I saw more responses to Prozac. Oh, it's been decades: I've seen a lot of patients have great responses to Zoloft, and because of the shorter half-life issue, I prescribe it a lot. Oh, the other good/bad thing about Zoloft-- the big dose range. The FDA max is 200 mg. I've seen it used up to 300mg and that patient had no side effects (at all) and the OCD experts apparently go even higher off label. While most people seem to need 100-200 mg for a good response, some people feel better on 25mg, and so for them it's nice to have the option of very low dosing. The bad is that for those who need the whole 200mg, well, it can take a while to get there.

Paxil: This was definitely good stuff, seemed to be well-tolerated, work well, my best guess was that it was more calming, or at least less agitation producing than Prozac, I've prescribed a fair amount of this stuff and still have patients on it who do very well. Time--- two bad things I've seen: a few patients complain of weight gain. I had one patient, certainly the outlier, who gained a huge amount of weight. I would have taken her off the medicine, but she didn't want to stop it. She'd been a skinny kid, she didn't like being the skinny kid, while she didn't like being so much heavier, I was shrink number 3, she'd been on lots of medicines, had lots of diagnoses, her life was a wreck. I'd stopped everything, started 10 mg of paxil, her life was better than ever, and she'd rather be heavy and happy. The years went by, it started to bother her that she was so heavy, eventually changed to Serzone, dropped a lot of the weight, and last I saw her, was still well. Oh, but then the really bad: some people had withdrawal syndrome. Most didn't. But of those who did, well there have been a few where it lingered, where the patient had this very disconcerting and distressing sense of being off balance. I still use Paxil, it still helps people, but before I start it, I tell people there is this risk, and I never just stop it, there's always a slow taper, pill breaking, and every other day dosing when it's time to come off. This helps, and I'd say it's been a while since I've heard about a withdrawal syndrome, but really, the numbers I'm dealing with are too low to be relevant.

Luvox: I've only used this a handful of times. Seems like an SSRI. It's hype is it's indication for OCD. It seems to be the least used SSRI and the poll thingy wouldn't let me have all of them as choices, so this one got dropped. By all means, write in with your Luvox experiences.

Celexa: I've worked in clinics where I get to see other people's prescribing habits, and I worked in a clinic with a doc who liked using Celexa in very high, over-the-FDA-recommended, doses. Seems like it works and is well tolerated. I have a few people on it, mostly they came to me on it. I tend to forget it exists.

Lexapro: Like the others, it seems like a good medicine. Well tolerated, and it works when it works and doesn't work when it doesn't. Same side effect profile as the others, people don't complain much about it. This was our voter's favorite and I wonder if it's because it's the newest that it's what lots of people get prescribed. I think there are now a few of people out there on Lexapro because I've thought "It's the favorite of our readers."

And the poll results, of 105 respondents:

Prozac	16 (15%)
Zoloft	25 (23%)
Celexa	16 (15%)
Paxil	14 (13%)
Lexapro	34 (32%)

The Questions You Asked

As I go through my day, I often think about the things people write in the comment section of our posts. Often we get questions, sometimes we forget to respond, sometimes I simply forget they are there, sometimes we save them for the Podcast, and sometimes, well, they are too out there to even begin to address.

I'm going to take a moment here to backtrack and talk about some stuff that's been asked...doing it as a post instead of in the comment sections.

Flash recently visited an old post and asked:

A third year med student also considering psychiatry. I have liked many different things in all of my rotations but I keep coming back to psych. I just had a daughter and suddenly lifestyle is very important. Have psychiatrists on this blog found that they could have controllable hours/live decently/pay back loans with psych? I would love to work part-time when I complete residency, but is this even possible?...Can I retain my fun-loving self if I become a psychiatrist? Obviously I am serious, sincere and compassionate in my patient encounters. I wouldn't be considering psych if I was otherwise. But could psych drag me down?

Hi Flash and thanks for visiting. In terms of money and lifestyle: many issues here. We're all so old-- back in our day loans had to be paid off in 10 years. Now, I hear residents talk about their quarter million dollar school debts (no, I'm not kidding) that go on for 30 years. Mortgage number two, essentially. I work part-time and psychiatry is particularly amenable to part-time work and controlled hours. Employed spouses help. Lottery tickets are good. I don't know any starving shrinks, but the ones I know who are the sole support for their families do work long hours. Rich dead relatives can be useful as well. If you're heavily in debt, if your spouse is a school-teacher, if you have a fondness for vacation homes, Versace bags, and large boats, don't be a psychiatrist. You can retain your fun-loving self. Psych could drag you down, but not as much as a lot of other medical specialties. I do know a psychiatrist who got through school working as a professional clown.

And Lily wrote in one of her comments:

My psychiatrist never seems hopeful. I don't get it. I think all of the three of you are too good to be true.

Are we too good to be true? I've been thinking about that. ClinkShrink and Roy are definitely as good, if not better, in real life than they are on the blog. How can a guy who names his bird "Monkey" be bad? And someone who loves cats and devotes herself to society's criminals? SuperClinkShrink not only runs zillions of 9 minute miles, cares for thousands of downtrodden criminals a year, but she stays with my dog and my kids when I'm away.

Me? I think I'm better on the blog. In real life, I'm just a shrink with a strange sense of humor and a blog. More often then not, I click (not clink) with patients, occasionally someone credits me with saying something that really helps-- usually something that makes them feel understood or vindicated -- and often people credit me with writing prescriptions that help them feel a whole lot better. Hopeful? I am kind of hopeful and excited at the beginning of someone's treatment. If it's gone on a while and the patient is getting discouraged and the meds aren't working, I keep plugging away, but the excitement wanes. When we're talking years.....well, in terms of hopefulness, I readjust the goals, at least in my own head. Here and there, someone pushes my buttons and I think I do all the things all the other shrinks out there do. My strengths: I return phone calls, I'm really good at that, and being a psychiatrist who does psychotherapy as well as prescribes medications reasonably competently (I hope) has become a niche market-- all those folks doing 10 minute med checks make me look really good.

And for the final question in the comment section:

When is pizza?

In my personal experience, there is never a bad time for pizza. Pizza is best in New York City (the greasy stuff at Penn Station is particularly fabulous). I don't like many toppings and pepperoni is totally out, destroys the stuff if you ask me. Happy to try the latest greatest Baltimore's best as soon as I shake this cold. Please send chicken soup.

This Post Is A Lie

Everything I'm about to say in this post never took place. I'm making it all up. I'm putting up this hypothetical story because it could happen someday, or maybe it already has happened but I just don't know it. Anyway, I'd like your thoughts.

Here's the story:

I'm sitting in my prison clinic and I hear inmates sitting out in the hall talking. One of the inmates happens to be my patient but he doesn't know I can hear him. He is bragging that the first time he met me he "told Dr. Clink all kinds of stuff" and got put on meds. He added that when he gets out of prison he will be "set" because he'll have "a check for life". He doesn't mind taking meds because the pills he gets are "good stuff that helps me rest" and that what he doesn't take he trades away.

Curious, I pull his chart and look up his intake history which I completed two months before. When I saw Inmate X then I noted that his hygiene seemed a bit poor but he was calm and polite. He was slow to answer questions and at times seemed distracted as though listening to internal stimuli. He was evasive about questions regarding his past psychiatric history and refused to elaborate upon prior symptoms or treatment beyond acknowledging one hospitalization in his late teens (he's now in his mid-20's). He didn't remember the name of the hospital and couldn't or wouldn't tell me why he was there. He was not suicidal. His speech was sparse, and although not overtly thought-disordered his questions at times were a bit 'off the mark' and tangential. He acknowledged feeling "paranoid" around other inmates but no clear delusions were elicted. The rest of his mental status examination was unremarkable.

Concerned about possible psychosis I start him on risperdal. At followup visits he reports medication compliance but gives no additional information other than that found in the intake history. No new or additional apparent symptoms are seen at followup.

So here are my questions, which I'm particularly interested in having our psychiatrist readers address: Does this patient truly have a psychotic disorder or have I misdiagnosed him? What would you do to differentiate psychosis from malingering? To differentiate malingering from "faking good" (or bragging) in an inmate with a real psychotic disorder? What do you do when the social worker comes to you to fill out entitlement papers on this inmate who has announced his intention to defraud social security?

Thanks in advance for your thoughts. I await your ideas.

Will This Medication Help Me?

I've been asked this question twice this week. I think the question is more interesting for the reason why it is being asked than for the actual answer. Even after I've explained the diagnosis and what it means, discussed my treatment recommendations and the risks and benefits of treatment, even after the patient has agreed to try the treatment, they still have to ask if the medication will work.

In prison the obvious reason why someone would ask me this is because it's a prison. Inmates inherently aren't going to trust what they're told or the people treating them. When I hear this, I know that what the patient is really saying is: "Are you telling me the truth? Or are you just giving me something to placate me and get me out of your office?" At other times they are asking this because underneath it all they worry that they may never get well. By the time I see some of these guys they have already been treated by with a list of medications the length of your arm. They may be frustrated and nihilistic about trying anything new, or anything they think they've tried before. Remoralization is the key here, to remind people that they should never give up or lose the hope of getting well. Building trust is a secondary issue, one that may not get accomplished during a single incarceration. Trust is an individual issue that is built up gradually with each patient contact. It can also be fostered (or undermined) by your reputation within the facility. My patients talk to one another, sometimes because they're celling together. The trust question is usually settled before they come to my office on that basis alone; it usually is only an issue nowadays for the guys who have never met me before.

When I am sked, "Will this medication help me?" I know the best answer I can give is, "I believe it will. I know I will do my best to help you."

My Three Shrinks Podcast 33: Inane Banter

[32] . . . [33] . . . [34] . . . [All]

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Sorry for the delay in posting podcasts. I didn't get this posted last week due to a family emergency, but should be regular for a while now.

Podcast #34 will feature a guest speaker, Mark Komrad MD, who used to have a nationally syndicated radio call-in show about psychiatry. Be sure to check that out next week.

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September 16, 2007: #33 Inane Banter


Topics include:

• Q&A from Jennifer: "In your relationships with the greater world, do you find that you are more compassionate and understanding when it comes to putting up with the foibles of people since you have a greater understanding of the brain? When you see people in traffic driving like they own the road, do you still simmer and think dark thoughts like the rest of us, or do you think, 'well there goes a person who clearly has issues of narcissism (or whatever), and I just hope he doesn't smash into anyone'? Do you find the inane banter of teenage girls less headache inducing because you know the stage is only one of a thousand they will go through on their way to the grave and Oblivion? If a really religious neighbor keeps bugging you about your lack of faith and tries to nag you into going to church with her, would you just smile and thank your stars that you are free of 'invisible friend' delusions? If any of these scenarios are true, I think I may need to go into psychiatry."
  We do a decent job of answering these questions.
  
  
• American Visionary Arts Museum (AVAM). Clink discusses her observations about this Baltimore museum and some critical comments noted about the squelching of creativity by Psychiatry.
  
  
• Involuntarily medicating an "incompetent" defendant. Clink discusses a Baltimore Sun story (couldn't find link) about changes in Maryland created by "the Kelly case". It has now become harder to medicate defendants who are not competent to stand trial.
  
  
• Q&A from Emily: "Have you read the book called 'Crazy: A Father's Search Through America's Mental Health Madness' by Pete Earley? It is about the criminalization of the mentally ill. When I read it, my mind was opened to the phenomenon of mentally ill people who commit crimes while under the "influence" of their symptoms, and are punished by being imprisoned rather than getting adequate mental health care assistance.
  A few questions for you:
  -Do you feel that prisoners who require mental health care are able to be receive adequate assistance while locked up?
  -How do you feel about mentally ill prisoners? For example, a paranoid schizophrenic who committed acts such as breaking & entering, destruction of private property, etc while hearing voices instructing him to do so, and winds up in prison rather than a psychiatric hospital. Do you treat people in similar circumstances?
  -Something else that the book talks about is mentally ill people who are arrested and put in jail, then deemed incompetent to stand trial and sent to psychiatric hospitals until they can be stabilized, then sent back to the jail where they rapidly decline again for a number of reasons before they can stand trial. And the cycle goes on and on.
  -So I was wondering how much of this you witness in your daily work. How often do you see people that you think should be in a psychiatric facility instead of a prison? How big of an issue do you think it is, or what do you think should be done differently?"
  
  Clink addresses these questions, and also her contact with Pete Earley, and about another book of his, Hothouse, about Leavenworth Prison.
  

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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.