Guest Blogger Dr. Andrew Angelino on AIDS, Russia, and Collaboration in Medicine

Every month, the president of our state psychiatric society writes a column for the newsletter.  This month, I read it and thought the column, directed only at psychiatrists, would make a good Shrink Rap post.  Dr. Angelino has graciously allowed us to reprint his article:

“I’d like to talk to you about this patient….”

Some presidents follow a format for these columns.  I have nothing against formats except that I hate them for their…well, “formatness.”  The way I see it, I get to write to you all about 10 times this year and they’ll print what I write pretty much for free and without question, as long as I make some degree of sense and don’t embarrass myself or the profession too much.  So, what I’m really trying to say here is, I hope you enjoy what I have to say. I hope it makes you think a little, and more importantly, I hope it makes you want to talk to another psychiatrist a little, because that’s my goal as your president – to get you involved in the conversation.

I just got back from Russia.  I spend about a week or two a year teaching AIDS Psychiatry in various cities in Russia.  Nowhere glamorous.  Usually, I get to go deep into Siberia in the middle of winter and freeze off body parts.  Although, there is something to be said for opening a conversation with “The last time I was in a Siberian prison….” 

AIDS Psychiatry is an interesting little niche.  Basically, I see patients with HIV infection who have mental health problems.  For the most part, people think that the role of the psychiatrist in this area is mostly dealing with grief or other adjustment issues – basically talking to folks about their concerns over having a life-threatening infection.  Slightly more sophisticated, some recognize that the action of HIV in the brain causes mental problems – dementia and major depression are examples.  But what many don’t think about is that HIV infection is an outcome of mental illness.  That the reason we have such a high concentration of individuals with mental illnesses in HIV clinics is that their mental illnesses render them vulnerable to behaviors that lead to outcomes like HIV, hepatitis, imprisonment, homelessness and other disenfranchisements.  And once they’re infected with HIV, we have complex mentally ill patients that now have to try to manage a life threatening infection along with their mental illnesses.  Basically, that’s my job: help the most vulnerable manage an incredibly difficult task, for the rest of their lives.

Now I’m not telling you this to toot my own horn.  I’m telling you because I learned, from a whole lot of firsthand experience, that all this integrated healthcare, medical home, accountable care mumbo-jumbo really works.

In my clinic, the psychiatrists work in rooms next to the medical doctors.  Today in clinic, I spoke to Mark Sulkowski, infectious diseases doc specializing in HIV-hepatitis C coinfection.  We have several patients together.  I know I can knock on his door anytime he’s not with a patient to discuss a patient or the latest new drug for hepatitis C (we have two new protease inhibitors that will likely increase cure rates).  We also have social workers and pharmacists and case managers and primary care docs and OB/GYNs and dermatologists and ophthalmologists and neurologists.  And we all write in the same charts and manage the same patients together.

In Russia, no such system exists.   Last week, we were discussing the tricky problem of managing patients with HIV infection, active tuberculosis, and active injection drug use.  The biggest problem is there is no system.  TB is treated in the TB clinic, HIV in the HIV clinic, and drugs in the “narcology” clinic (which is independent of both psychiatry and general medicine).  And nobody talks to anybody else.  The Russians are fascinated by the stories of how my clinic, and other HIV clinics in the US with some of the same services, manage complex patient issues.  They are in awe of the resources we can bring to bear to overcome a problem like adherence to medications.  And they are also in awe of our commitment to the public health that permits us to take a stand like mandatory TB treatment using directly observed therapy.

At the MPS annual meeting, I made a short speech.  I said I wasn’t going to stand up to say we have a broken health care system because I didn’t believe it, and I still don’t.  I think we have great health care in the US – it’s just not universally very focused.  We’ve let freedom to choose (a really good thing) gum up a system that can, and sometimes does, work wonders. 

And our profession has taken that a step farther.   We’ve lost ourselves a little in psychiatry and forgotten what makes us most useful to our medical family – our ability to influence attitudes and behavior.  We’ve occasionally let our patients excuse behaviors with mental symptoms and allowed them to fail because we sometimes overvalue their free will to choose to ruin themselves. 

We face issues in the approaching health care “reform.”  The same kinds of issues Russia is facing.  Do we remain in silos and let patients fail because they don’t integrate for us, or do we step into each other’s spaces and learn to co-manage difficult cases?  Do we let payors divide us and limit our work together, or do we strive to demonstrate how effectiveness in one compartment can have benefits in another, thus balancing out for the “whole patient?”  Do we become so specialized in our area that others with no medical training threaten to replace us because they are willing to work cheaper, or do we demonstrate the enhancement medical training has on our ability to integrate with our medical colleagues?

Every time we pick up the phone to talk to the patient’s primary care physician, we integrate health care a little more.  Every time we fax over a note, or send a short (encrypted) email, we integrate a little more.  Shared access to an electronic medical record between Emergency Department doc and psychiatrist?  You bet that’s integration.  And you’re already doing it all the time, I know.  So this “reform” should be a breeze, right?    I guess that’s why I can spend some of my time working on the Russian problem.

My Doctor, My Expert

In Dinah's post "The Chapter I Wish We Had Written" an anonymous commenter wrote about his problems finding an expert witness for his or her employment discrimination case (since I don't know if Anonymous is male or female I'm going to use a standard male pronoun in this post---apologies if I got this wrong). Anonymous asked his doctor to help with the case, but he refused. He explained to Anonymous that he would be a biased witness and Anonymous also understood that the doctor's involvement might affect the therapeutic relationship. Anonymous's doctor gave her a number of referrals to forensic psychiatrists, but since he was not working with an attorney no expert would take the case. Anonymous was understandably frustrated by this situation.

I wanted to write about this because this situation comes up fairly often and I get calls from friends, colleagues and former students asking how to handle it. I've already written about what to do when you get served with a subpoena in my post "When Lawyers Call."

First of all, I think Anonymous's doctor was particularly astute to recognize the dilemma that arises when trying to help patients in situations like this. I try to prepare psychiatry residents during their training to help them handle this problem, but in the days before forensic rotations were required in residency doctors didn't get that preparation. Anonymous's doctor is either young enough that he had forensic education during residency, or old enough that he got some real-life experience with it. Either way, he was right to recognize that he could be biased and that he was not in a position to offer a forensic opinion, and to make a referral to others who could.

In civil litigation expert testimony is usually needed to address the following questions:
-what is the plaintiff's diagnosis?
-what are the symptoms of that illness and how do they impair the plaintiff's life?
-what is this treatment for this condition?
-has the plaintiff improved as much as he will improve?
-what caused the plaintiff's condition?
-what are the plaintiff's permanent damages?

A treating clinician is usually called as a "fact" witness. A fact witness is someone who testifies about information they've directly seen or heard. Fact witnesses can't draw conclusions or offer opinions about their observations, and they can't be paid for their time testifying. Expert witnesses are allowed to draw conclusions or offer opinions about their observations.

Sometimes it gets tricky sorting out whether or not a treating clinician is being offered as a fact witness or as an expert witness. For example, a medical diagnosis could be considered a "fact" because it's a piece of information documented in a medical record. Testimony about a medical diagnosis could also be considered expert testimony, because the doctor is drawing a conclusion from his observations: ("I observed a sad expression and the patient reported persistent feelings of anhedonia and worthlessness, so I concluded the patient had clinical depression.").  It's important to clarify up front whether the clinician is serving as a fact witness or as an expert witness.

Role clarification is also important because you also have to clarify who is paying you and for how much. Some unscrupulous lawyers may try to call a doctor as a fact witness, knowing fact witnesses can't get paid for their time, but then will try to squeeze an expert opinion out on the stand regarding causation and damages. Shame, shame, on these folks! If you are qualified as an expert on the stand, you are entitled to expert witness fees.

Regardless, generally accepted ethical guidelines state that it is a conflict of interest to serve as both a forensic expert and treating clinician. If you end up stuck in that position---say you can't get out of a subpoena and you are required to offer expert testimony about a patient's diagnosis and factual information about treatment---how do you avoid looking like a fool or hurting your patient?

First, admit what you haven't done as a "real" forensic expert: you haven't interviewed collateral informants, you don't have all the investigation reports or records, you don't know your patient's entire litigation or criminal history, or the extent of pre-existing injuries, etc etc. For all these reasons, you are unable to offer an ultimate opinion about causation or damages. No one can force you to form an opinion if you have none. In this situation, "I don't know" is the correct answer.

If you know you're going to have to testify, prepare your patient in advance for what you might have to say. Because you're given access to many personal areas of a patient's life, some irrelevant but damaging information could be brought out in court. No one should be surprised, particularly not in a negative way, about what is being said. A treating psychiatrist should also be prepared for what could be said about him in court: How many times did you take your board exams? And did you pass? How much money do you make from expert testimony? Did you consider other possible causes of your patient's problem? Why didn't you do (X, Y or Z)? A clinician could be left feeling like the shoddiest doctor on earth, and that isn't going to help the next time the patient comes into the office.

Guest Blogger SG on How the Pharmaceutical Companies Have Damaged Psychiatry

SG put a comment on our last post on The Chapter I Wish We'd Written on Bad Psychiatrists.  With permission, I'm making part of those comments their own post.  I gotta tell you, SG, we shrinks aren't so happy about these issues either.

Per SG:

I don't think the issue is so much a few bad shrinks but bad psychiatry. What I object to most is the pervasive compromising of science by pharmaceutical companies and all-out advertising.

This toxic influence is so pervasive that one comes to the forlorn conclusion that evidence-based medicine as it is currently practiced is really just a way for pharmaceutical companies to generate new revenue streams. The companies are so savvy they realized if they own the evidence through biased studies and suppressed trial data (failed studies, nasty side effects), they would have physicians eating out of their hands and prescribing their pills for whatever they wanted. I really think this dynamic is similar to state ownership of the media by totalitarian regimes.

Of course this is endemic in all of medicine, but psychiatry is uniquely vulnerable to this phenomenon because it has become so rigorously based on medical therapy (read: pills) since the DSM III ushered in the new "biologically based" model of mental health.

I refer the posters on this thread to the 1boring old man website in which a retired psychiatrist has been relentlessly examining internal emails between pharma execs, presentations by prominent psychiatrists like Madhukar Trivedi, seriously compromised studies like STAR-D, and various political infighting between powerful psychiatrists.

It's all very vertiginous and one comes away with the conclusion that the last 30 years of psychiatric "breakthroughs" are largely built on sand.
 
I think it is imperative that psychiatry look at ALL the evidence in evidence-based medicine, even if it provokes cognitive dissonance.

We must remember this about evidence-based medicine: it works on paper, but when you factor in human bias, fear, greed, and stubborn attitudes, you could have the most air-tight science (or evidence) in the world, but if it doesn't tell us what we want to hear, then the medical community automatically thinks it's flawed. How is that true evidence-based medicine?

It's time for psychiatry to come to some harsh truths and own up to them so ALL psychiatrists, even the good ones (and yes there are some good ones!) can practice at a higher standard. Even if a psychiatrist does everything right these days, I know they could do far better if they had a more honest and transparent evidence base to draw on.

The Chapter I Now Wish We'd Written: Bad Shrinks

When Jesse read our Shrink Rap book, he said we were too nice to psychiatrists in it-- that we didn't mention that there are some really bad psychiatrists out there and he thinks part of the venom towards psychiatry comes from the whole rushed 15 minute med-check culture.

I thought about this and I thought, really?  We have a whole chapter called When Things Go Wrong and we discuss a psychiatrist who is not sensitive enough to a patient (though, granted, the patient is overly demanding and overly sensitive--so I guess not the best portrayal of insensitivity by a shrink), one who is rigid in her formulation to the point of almost destroying a family, one who prescribes medication that makes a patient fat and diabetic, and finally, a psychiatrist who is outright unethical and criminal: who defies all boundaries and gives her patient prescriptions for narcotics to bring back to her!  Like how much worse could I make the shrinks? As one Amazon reviewer said,

The authors are careful to include what might be called opposing views. They give some space to the anti-psychiatry movement, and they consider the recent cases of medications that seem to cause suicidal thinking in some patients. But they balance that against the suicidal thinking that is prevented in some other patients by the same medications. They also talk about the influence of drug companies in a fairly open way.

There are no heroes here. The authors aren't in the business of justifying themselves, and one or two of the fictional therapists we see in the book do spectacularly bad jobs and harm patients.

But Jesse is right,  overall the examples portray psychiatrists who are thoughtful and caring, and while we tried to "explain" our work, not justify it, we did not talk about psychiatrists who just plain bad, or those who are probably good but who put such an emphasis on making money that they don't give the work the time it needs.

So why didn't we (or "I," since this is my post, never discussed with my co-blogger/authors) talk about 'bad' psychiatrists in a broader way?  I'm going to go for bullet points here:

• We talked about the pros and cons of split therapy, and there are pros.  Clink works in a prison where she sees up to 3 patients an hour.  She's a wonderful, smart, and thoughtful shrink, but I even don't believe that criminals should have psychotherapy with a psychiatrist, especially given that hard-working, insured, law-abiding people in free society can't afford this.  There are all types of issues that make some rapid worse than others: if there is a single chart and the doctor has access to information from the therapist and the care is coordinated, if there are reports from other professionals treating the patient, such as in a day hospital or program setting, where assessment includes a team approach, medications can be managed well with less face-time with the patient.  In a private practice setting, however, rapid care may mean shoddy care.
• At the time we wrote the book, I had never heard of an outpatient, private practice, psychiatrist who sees 40 patients a day such as the one portrayed in the NYTimes article by Gardiner Harris.  I'd heard of 15 minute med checks, but in the clinic where I work, I sometimes see patients for 15 minutes, or less, not because I'm scheduled so tightly, but because they have nothing to say...all is well,  a family member is there and confirms that things are going smoothly, their therapist is in the room and says things are fine, and the patient wants their prescription refilled and to get out.  I had never heard of an outpatient psychiatrist who sees every patient, regardless of their needs, in a one-size-fits-all 15 minute slot.  I can't imagine how this can be done well.  The New York Times may want to portray this as how psychiatry is now routinely done, but it's not.  
• Some psychiatrists are insensitive... we did reference the idea of a psychiatrist "with the social skills of an iguana"  (I hope we didn't insult any iguanas!), but the idea of interpersonal sensitivity is a hard one to capture--- people are very different in what they want, and one person can relay a story with "Can you believe he said THAT?"  While another person would find THAT as being a perfectly reasonable thing to say.  There is no psychiatrist out there who is everyone's perfect fit, and even the people I might think I'd never refer to, likely have devoted patients with good outcomes. 
• The things that often trouble patients the most are endemic to all fields of medicine these days and not just psychiatry and they don't objectively make a doctor "bad," (maybe over-scheduled, disorganized, or forgetful) and include the large areas of running late and keeping patients waiting, or of not returning phone calls.  Patients are often angry about this---often rightfully so--because it leaves people feeling like they aren't cared for or respected.  I'm not certain what there is to do about this one.  

In the end, I decided it's fine that we didn't write about the general topic of 'bad psychiatrists.'  None of us felt any need to pass judgment on our peers, and we created our fictional psychiatrists with the idea that this is how it's supposed to be-- others can use it as a model of what to expect.  Our shrinks listen, they are thoughtful and respectful, and they spend time with their patients and consider the impact of their work within the context of their work environments.  Maybe unrealistically so, but why not have an ideal to strive towards?

Understanding the Research on Psychotherapy Trends-- a Discussion with Dr. Ramin Mojtabai

For whatever reason, it bothers me when media says that psychiatrists don't do psychotherapy, and lately, it happens a lot.  What am I, chopped liver?
They quote a study by Mojtabai and Olfson in the Archives of General Psychiatry, and say, "Only 10.8% of psychiatrists see all of their patients for psychotherapy."  Is that really true?  Is it really relevant?  I tried to read the article and I wanted to understand how the study was done so I could think about it myself, but I didn't understand how the research was done-- Roy thought it was based on CPT codes, then he said it wasn't.  So why not go to the source?  I asked Dr. Mojtabai if he would have lunch with me and tell me how the study was conducted.

If that got you curious, please read about it on over on Shrink Rap News!  You're welcome to comment there if you're physician, or to surf back here and tell us what you think.  Ramin says he's interested in what people think, and he's been very kind about humoring me, both over lunch and in the many subsequent emails over the details.

The Ten Percent Solution

Duane and others have mentioned this "10% rule," which essentially suggests making small changes in medication doses over extended periods of time (~1 year). A 10% decrease in dose every 4-6 weeks is often quoted. It's a rule that makes a lot of sense.

In response to a change in the brain's biophysicochemical stew (meds, trauma, chronic stress, etc), it generally takes neurons a couple weeks to fully generate new or recycle old protein machinery -- to adapt to changes. This duration can be shorter for some proteins, longer for others. Thus, small changes would be expected to minimize the shock to the system. This just makes good homeostatic sense.

There are problems with this as dogma, however. There is not useful research, at least that I am currently aware of, to demonstrate whether the "best" interval percentage change is 10% or 5% or 25%. We also don't know if the "best" interval is one week, two, four or eight. Or which medications and their affected pathways are best tapered at what intervals and amounts. Please share original source (ie, PubMed) links to peer-reviewed research below if you have relevant references.

Quacks....

From Broom Hilda

With thanks to Ross who sent me the link to this cartoon.
I'm wondering what she wanted validated?  Her parking ticket, perhaps?

Guest Blogger Dr. Jesse Hellman: Tarzan, the Computer, and the Unconscious

In Tarzan of the Apes, written a hundred years ago, the protagonist is born to a couple cast up on the coast of Africa by a shipwreck. His parents die, and he is brought up by a female ape, Kala, who had lost her baby. He learns English, but not its pronunciation, by looking at the picture books his parents saved from the wreck. Tarzan develops the physical abilities of a jungle denizen, but also shows a remarkable intelligence and nobility of spirit. This is, as we learn, because his father was an English lord, and Tarzan is thus the true heir to the title Viscount Greystoke (I will add that Jane is from Baltimore).

We today know that the human personality would not develop as Edgar Rice Burroughs supposes it could. Nobility of character certainly does not come from an ancestral title. The brain requires certain input to develop normally. In understanding the mind, however, we can use the computer as an imprecise analogy.

The computer as delivered, like the baby, contains hardware. The baby has the ability to use certain software: It starts to learn language. Unlike a computer, however, it develops connections to its caretakers. New languages can be learned later, new habits or customs, but the oldest language and culture often has attributes that stay with the individual, even if in the background, throughout life.

Recent studies have started to explore the origins of the sense of morality, fairness, and sharing in chimpanzees and other primates. Certain traits that were assumed to be totally learned are now thought to be somewhat hardwired. The differentiation between hardware and software is not as clear-cut as was once thought, but it is still useful. Psychiatrists treat the whole person: There are difficulties that arise primarily from hardware not functioning perfectly, others purely from software or programming, many from both ("nature and nurture"). At one time schizophrenia was thought by some to come from a baby's experiences with a "schizophrenogenic mother." Not any more. We don't know the precise origin of many conditions we treat.

A child is born with a temperament that is evident at a very early age. Traits as diverse as confidence, distrust and shyness may show up very early. Some babies have a sunny disposition, others are more negative.

Just as on the computer, certain programs may have conflicts with others. While we may steer the ship, the conscience may control the compass, and our drives affect the winds and tides. Loyalty to one’s family may conflict with duty to one’s country (Antigone), or the wish to be independent may clash with the wish to be cared for. Some conflicts may be primarily behind the scenes, perhaps more obvious to others than to ourselves. Anxiety may be an outcome of our conflicts.

Free Will (see Noni Mausa’s comment in Are We Not Thugs?) is not as obvious a concept as it once was thought to be. Decisions are not completely determined by that with which we are consciously aware. The law needs to have one concept of free will and causality, religion has another, depth psychology another yet.

What we think and feel about others is not determined simply by what happens between them and us. Our reactions are influenced by multiple layers of past experiences, prejudices, our competitive and even sadistic yearnings, the need to be loved and to love, and factors that might be trivial to one person but determinative to another. It is not at all easy to be aware of what leads us to do what we do.

A new test had been done which would establish the truth about Tarzan’s parentage; the results in a telegram that had come from Paris. Tarzan knows that Jane Porter is loved by William Clayton, who had inherited the estates and title that might be rightfully his. He hopes that Jane loves him, but before he could speak with her, in a moment of doubt and insecurity, she promised her hand to Clayton, choosing the certain over the uncertain, respectability over passion. What interfered with his ability to see that Jane loved him, and to act sooner?

He reads the telegram. “Fingerprints prove you Greystoke. Congratulations.” One word from Tarzan would take everything from Clayton, and so now from Jane.

Of what use is a peerage if we have lost her whom we love? Could our actions be influenced by the fear we had when our father died?

Clayton asks Tarzan what he knows of his origins. Tarzan crumples the telegram and throws it aside. He answers simply, “My mother was an Ape. I never knew who my father was.”

Psych Meds are THE Problem: A Post for Duane Sherry

Shrink Rap prides itself on being a take-all-comers place for open dialogue about the issues and controversies in psychiatry.  Five plus years, and the feel of our blog has gone through many evolutions.  In the last 6-8 weeks, things have gotten very heated around the topics of involuntary hospitalizations and the question of whether medications cause illness or treat illness.  

I see patients who walk in the door in distress.  The only people who walk in feeling well are those who have been treated by someone else and are coming to continue treatment, either because their shrink moved, they moved, something changed.

Once in a while, someone comes in and they are in distress and they are already on psych meds and I look at the regimen and say "No wonder you feel badly, you're on way too much medicine" and I stop things.  Mostly though, I start new medicines and I see people who were sick get better.  Some people have problems with medicines, but not like I hear people talk about in our comments section.  Here at Shrink Rap, people hate anti-psychotics. Very few patients tell me  that very low dose anti-psychotics bother them.  Medicines need to be added carefully, at low doses, and increased gradually.  The patient is supposed to get better: it they don't, the medicine should be stopped.  Sometimes people end up on a zillion medications, no better, and it's not clear why they are on them.  See: Medications: The Good, Bad & Ugly, and  You're Supposed to Get Better.  These are some of my views on treatment and medications.

It's not unusual that patients come in and casually mention in the course of a therapy session, "oh, I stopped taking the meds."  I ask why.  Side effects?  Felt they were no longer necessary?  I ask if they feel better without them (some do, some don't).  I'm here to help, and since I work in a totally voluntary setting, I may spout statistics, especially to someone with a high risk of relapse who was having no side effects and no problems with the meds and feels no differently off them-- but hey, you don't want to take medicines-- it's fine with me, and I'll hang out with you in therapy anyway. 

Duane Sherry has been visiting us for a while now in the comment sections and he feels strongly that medications are the problem, not the answer, and that people who think they are better are wrong.  He and I are seeing different before & after shots.  He asks if I give informed consent (funny, I do) and thinks people should explore different options such as orthomolecular therapies.  He's posted many links, and something gets troubling about the repetitive nature of it (at least to me) and something gets troubling about the accusatory tone, though he has really toned down the blatant --you're an idiot-- comments. Thank you, Duane, this has meant a lot to me.

So let me give Duane a moment here to get out his message of Meds are Harmful / Psychiatry Sucks here on the main page of Shrink Rap.  Duane, you're still welcome to comment, but please stop with the repetitive links, and please keep the tone respectful.  You might want to consider getting your own blog where like minded people can have a forum.

Duane says:

The drugs numb.
They provide temporary relief.
And that's all they do.

The greatest injury happens in their long-term use... They are addictive, because they meet the medical definition of physiological addiction in two vital areas:

a) Increased tolerance
b) Measurable effects during withdrawal

Have your patients look at the "side effects" more closely... Really look at what the drugs do.

Then see how many want to be placed on them.

Here is Duane's website...funny, no place for comments:
http://discoverandrecover.wordpress.com/wellness

Here are some links Duane likes:

http://www.foodforthebrain.org/content.asp?id_Content=1635
http://www.vitamindcouncil.org/health-conditions/mental-health-and-learning-disorders/depression/
http://www.townsendletter.com/Nov2009/hoffer1109.html
http://www.youtube.com/watch?v=aBjIvnRFja4&feature=channel_video_title
http://www.madinamerica.com/madinamerica.com/Timeline.html
http://breggin.com/index.php?option=com_content&task=view&id=40&Itemid=52
 http://recoveryfromschizophrenia.org/therapists-guide-to-reducing-medications/

Duane, Please put any other links you'd like in the comment section of this post: your personal space on Shrink Rap.  If you'd like, in future comments you can say "I'm putting links up in my space on Shrink Rap" and link back to this post and put them in the comment section here.
 
For the most part, we need to agree to disagree.  I don't believe I am going to sell Duane on the idea that medications sometimes help people live better lives.  And I don't think he's going to sell me on the idea that they should never be used. 

To my co-bloggers: please forgive me. 

Article on Marsha Linehan in Today's NY Times

Please visit: Hot Grand Rounds-- The Summer Solstice medical blog posts with the pretty pictures, including a pink urinal with teeth.  One could ask for anything more?

And Please Visit Clink's post over on our Shrink Rap News blog on ethical issues related to the psychological report on the suspected Anthrax killer.  
When you're finished reading, please return Here to comment.

****** 

From today's New York Times, Benedict Carey writes about  Dr. Marsha Linehan, the psychologist known for her work with DBT.  In "Expert on Mental Illness Reveals Her Own Fight," Carey writes:

Marsha Linehan arrived at the Institute of Living on March 9, 1961, at age 17, and quickly became the sole occupant of the seclusion room on the unit known as Thompson Two, for the most severely ill patients. The staff saw no alternative: The girl attacked herself habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on.
The seclusion room, a small cell with a bed, a chair and a tiny, barred window, had no such weapon. Yet her urge to die only deepened. So she did the only thing that made any sense to her at the time: banged her head against the wall and, later, the floor. Hard.
“My whole experience of these episodes was that someone else was doing it; it was like ‘I know this is coming, I’m out of control, somebody help me; where are you, God?’ ” she said. “I felt totally empty, like the Tin Man; I had no way to communicate what was going on, no way to understand it.” 

This is a great article, check it out.  Thanks, Jesse, for the heads up, and Rob, for the link. 

Suicide, Free Will, and the Shrink's Magical Ability to Predict Violence

I'm posting over my fellow co-bloggers today.  So what else is new?

Please visit: Hot Grand Rounds-- The Summer Solstice medical blog posts with the pretty pictures, including a pink urinal with teeth.  One could ask for anything more?

And Please Visit Clink's post over on our Shrink Rap News blog on ethical issues related to the psychological report on the suspected Anthrax killer.   
When you're finished reading, please return Here to comment. 

---------------------------------------------------

For a while now, we've been having discussions in our comment sections  about the issue of forced treatment: is it right or is it wrong?  Some readers are very clear: no matter how sick, no matter how imminently dangerous, no one should be held in a hospital ever against their will.  One reader tells us that suicide is a right of all persons as per their free will, and by the way, psychiatrists can't predict acts of violence and have no right pretending they can.  They should stand up to the legal system and say so, and not go along with the charade.

Both ideas got me wondering: is suicidal behavior that results in the attention of mental health professionals really a product of free will?  As psychiatrists, many of us believe that people have unconscious motivations--- they are guided by beliefs they are unaware they hold.  People commit suicide all the time-- In 2008, 34,598 people in the United States committed suicide, making it the 11th ranked cause of death.  Somehow they did it despite the proliferation of mental health professionals.  Many completed suicide with firearms, and my guess is that these deaths often occur without the immediate involvement of psychiatrists.  Those who wish to exert their free will to die often do so without alerting others or involving professional helpers.  It leads me to wonder if those that present to Emergency Rooms or to their outpatient psychiatrists might do so because they have an unconscious (or not-so unconscious) desire to be stopped.  Of course there are exceptions: those who are pulled off bridges, or discovered after a serious attempt that did not kill them.  Do we not summon medical care for an unconscious overdose victim on the theory that they may have wanted to die and we're interfering with the advancement of their free will?  

We put up a poll a few weeks ago where we asked if people would want to be treated by force if they had an episode of severe mental illness.  Of our 280 respondents, a majority, 57%, said yes while 42% said no.  Would the answers have been different if I'd asked a more provocative question: If you became psychotic and believed it necessary to kill your children, would you want to be treated?  It's too provocative a question for a poll, but I thought I'd throw it out there.  If you became demented, agitated, and combative towards those caring for you, would you want to be treated with a medication that increased your risk of death over the next year from 2% to 4%?

Don't worry, I won't be that provocative. 

The issue of predicting violence is an interesting one, and our reader is right that we're not terribly good at it.  Our most powerful magical tool is to ask the patient if they're planning to harm themselves or anyone else, and the truth is sometimes more legal than medical: we're told that if we don't ask and document, that if someone kills themselves, we'd lose a malpractice suit.  It does get boring asking perfectly well appearing people if they're thinking about suicide and homicide on each visit, but it is a required check box at the clinic.  If they say yes, we ask about a plan and intent, and it does seem it might be troublesome to the family if a hospital discharges a person who says they plan to leave to go shoot up a mall.  Or someone who has been actively psychotic, disorganized, and behaving in a dangerous manner.  There's medico-legal issues, but there is also common sense and kindness, and if you believe that someone who puts the barrier of the mental health field in the way of their violence may actually want help, even if they don't put it in those terms, then there is little to argue about.  Oh, go ahead, argue anyway.

Free will?  So many people who survive suicide attempts are glad they did.  So many who attempt do so for impulsive reasons that pass, or because they were intoxicated.  I'm not much for condoning a permanent solution to what are often temporary problems.

If you want to tell us that you were hospitalized for suicidal "ideation,"  this is another post for another day: I'm still thinking about that one. 

CPN: The Anthrax Report

--I'm posting this for Clink because she is in prison where she can't access blogger.


In ClinkShrink's post on Clinical Psychiatry News she points to some ethically troubling actions in the official investigation into Dr. Bruce Ivins's alleged involvement in the 2001 Anthrax attacks, including the sale of a report containing his medical records.  

 Use of Psychological Profile to Infer Ivin's Guilt is Problematic

Summer Solstice: "Hot" Grand Rounds on Shrink Rap

Shrink Rap is hosting our third Grand Rounds today on June 21, which is the first day of Summer. In keeping with the summer solstice theme, we asked for submissions that have a theme of "hot." However, "hot" may refer to not just  temperature, but also spiciness, luck, passion, anger, popularity, etc.

Our first Grand Rounds in 2007 featured a clicky brain, and the second featured the then-new iPhone 3G, complete with clicky iPhone apps. This time, we've used clicky pictures that exemplify the "hot" theme. (We didn't want to ignore the southern hemisphere, so if submitters live where June 21 kicks off the winter solstice, we asked that they feel free to use a "cold" theme and picture.)  I had planned to make a grid of all the pictures at the top of the post, by the way, but I've run out of steam.


We received 21 24 submissions this time: 11 via Twitter, 9 12 via email, and 4 via Facebook (3 were duplicates). [edit: I inadvertently left out three posts... find them at the end]

Walter Jessen from Highlight Health submitted the HOTTEST post for this theme: Surviving Summer: The Good, the Bad, and the Ugly.

The signs of heat exhaustion often begin suddenly. Symptoms resemble those of shock and may include feeling faint or dizzy; nausea or vomiting; heavy sweating; paleness; muscle cramps; weakness or tiredness; and headache. The skin may be cool and moist. The pulse rate will be fast and weak, and breathing will be fast and shallow. Untreated, heat may progress to heat stroke.

Ryan DuBosar on ACP Internist writes about protecting your skin from the SUN using the new sunscreen labels.

In addition to the new labeling, the FDA has proposed to limit the maximum SPF value on sunscreen labels to "50+", because there isn't enough evidence to show that products with higher values provide any more protection. FDA is now seeking public input on that. The FDA is also reexamining the safety information available for active ingredients included in sunscreens marketed today.

In A Medical Resident's Journey, Another Day, Another Summer... reflects on the different sorts of summer maladies appearing in the summer Emergency Department.

Heat rises from the sidewalks of the city. Backyard grills appear again. Sun dresses, outside tables, kites, picnic baskets, bike riding. The world welcomes us to summer. In the hospital, it is a time of great change. All of us – residents, fellows, medical students – are moving on in our journey. Over a period of a few weeks, we will be “promoted” to new positions in the hospital. Some of us – those who have completed their training – will be leaving, to become attending physicians at last.

Dr Nicholas Fogelson from Academic OB-GYN sent in One for the Medical Students -- on Presenting, explaining how med students can give HOT patient presentations. Okay, that was a big stretch, as we couldn't determine any link here to the summer solstice nor summer pictures. Wait, I've got it... at the end of each patient discussion, one should provide a very Summery presentation!

A student that never jettisons the note cards will never be an effective presenter.

David Williams from Health Business Blog gave us some HOT hospital clowns in action in Hospital Clowning: Video Introduction to Hearts & Noses Hospital Clown Troupe.

The clown aspect people think they get, but it’s hard to explain how empowering the professionally trained, dedicated volunteers are to the thousands of children and families they serve.

Brooke Douglas from DrPullen decided to inflame us with Inflammation and Diet: Inflammatory and Anti-Inflammatory Foods. 
Hot stuff!

The problem occurs when chronic inflammation occurs inside our body and we can’t see it or feel it. This chronic inflammation does not allow for natural repair and healing caused by the damaging ‘pro-inflammatory’ (saturated and trans) fats.

Bob Vineyard from Insure Blog sent in Georgia Piedmont Hospital Layoffs. In a move that's sure to leave docs and patients hot under the collar, an Atlanta hospital is laying off over 400 health care workers.

Georgia, looking for new revenue, decided the prudent thing was to implement a hospital bed tax. As with any other tax imposed on business, the customers (patients) pay the tax. The irony is, the bed tax was introduced to make up for current budget problems in funding Medicaid. It makes you wonder what will happen when Obamacrap expands the Medicaid rolls in 2014.

Zoe Brain sent in a post from Box Turtle Bulletin, which features "news, analysis and fact-checking of anti-gay rhetoric." She describes the post, What Are Little Boys Made Of?, written by editor, Jim Burroway, as HOT as in timely, radioactive, controversial. It is a stirring description of past "treatments" for homosexuality during a period when even having effeminate traits was considered a sign of disease. The long-term consequences to Kirk "Kraig" Murphy, a 5-year old in 1970 and the subject of a series of research papers, are chronicled here.

In this original BTB investigation, we speak with [Kirk's] family and friend who knew the real “Kraig” to uncover the truth behind [researcher] Reker’s greatest success story. Their stories reveals the tragedy of a terrible experiment on a very young boy which would haunt him for the rest of his life. It is not only an indictment of a man who built his anti-gay career on Kirk’s suffering, but a rebuke to others — those in the mental health profession then and in the contemporary ex-gay movement today — who would place their careers and agendas ahead of the well-being of this young boy and countless others like him.

Louise Norris from Colorado Health Insurance Insider sent in her HOT topic: Rate Review Process Does Not Keep Insurance Premiums Artificially Low. Last year or so, framing the whole health care reform discussion, a large California insurer announced 39% rate hikes. This post discusses a California bill that would require rate regulation by the state's insurance commissioner, which many states currently have, and a research article finding that rate regulation does not put insurers out of business.

Having rates approved by the DOI does not mean that the people of Colorado get smaller-than-average premium increases. Rather, it means that although our rate increases are sometimes substantial, we know that those rates are justified as a reflection of increasing claims costs.

South African surgeon, Bongi, blogs on Other Things Amanzi. He sent in Dolls Eyes, about his experience as a fourth-year medical student helping a woman with a tragic fetal loss.

i remember sitting there in that small labour room where mothers are usually introduced to their new babies while the registrar ran the sonar probe over the mother's swollen abdomen. i remember her bringing the probe to a standstill over the heart. we could clearly see the heart, but there was no movement. the heart was not beating. as we actually already knew, the baby was dead. all that remained was to tell the mother.

Erin Breedlove, who has cerebral palsy, submitted a post from her blog, Healthy, Unwealthy, and Becoming Wise, about what to say to children when they ask her, What's Wrong With You? 

To me, it’s a pretty poignant, honest question because there are some days that I’m not sure how I’d answer it to anyone, much less myself. As a future educational psychologist, I’m a fierce advocate for giving children all the information. No, they might not be able to understand the full extent of what you mean at their current age and stage of development, but trust me, they’ll appreciate it later... One of the most common questions I’m asked is about why I don’t use the “everybody’s different” response, and there are two reasons in addition to the ones outlined above. The first is that I believe that the response undermines the intelligence of a child, and that’s the last thing anyone wants to do during critical stages of development, and the second is that I believe that the only way children will learn and understand is to be inquisitive, so I appreciate that with everything in me.

Jacqueline from Laika's MedLibLog gives us the low-down on the question of Does Soy Relieve HOT Flashes?

The other phytoestrogen interventions were very heterogeneous with respect to dose, composition and type. This was especially true for the dietary soy treatment. Although some of the trials showed a positive effect of phytoestrogens on hot flashes and night sweats, overall, phytoestrogens were no better than the comparisons. Most trials were small, of short duration and/or of poor quality... One striking finding was that there was a strong placebo effect in most trials with a reduction in frequency of hot flashes ranging from 1% to 59%.

The med student at Metropolis Med posted on Action Potential about 5 Memorable Moments as a first-year medical student where she lost her cool (losing cool = HOT!). 

2. That time the med school dorm decided to test every smoke alarm.
3. That time we were assigned 250 pages of reading in one day.

Sarebear posted on Across and Inside My Universe about those times When the Doctor/Patient Relationship Becomes Heated.

Before I get into specifics, let me say that as a patient, when you are sitting there on the receiving end of some "heat", or ire, or intense aggravation, or anger, even, it is shocking, bewildering, and causes you to wonder what is wrong with you or what you did wrong, as the patient, to deserve what is happening. You are shocked because, if you've had enough dealings with this doctor (about a year, in my first psychiatrist's case, when this happened) you know that he normally conducts himself much more professionally; to see and FEEL such unfettered, intense, unpleasant emotion, directed at YOU . . . well to say it is bothersome is an understatement.

Rachael Watman from the John A Hartford Foundation blog wrote about the HOT topic of Helping Hoarders, profiling the work of Monika Eckfield RN PhD.

I interviewed 22 adults age 65 and older, six men and 16 women. My oldest participant was 91. Most of them lived alone. Most had hoarding behaviors to varying degrees all their lives. When you’re living with someone there tend to be checks and balances, and the home doesn’t get overwhelmingly cluttered. When a person gets divorced or becomes widowed they no longer have the checks and balances. Other life changes can also exacerbate hoarding behavior...

Julie Rosen of Bedside Manner, from the Schwartz Center for Compassionate Healthcare, wrote about the passion behind Massachusetts First Lady Diane Patrick and her experience of Compassion for the Mentally Ill. [submitted by Petra Langer]

Today, Mrs. Patrick’s advice to those suffering from depression is to seek help and to be open to compassion. “Because I admitted my problem, I allowed compassion to come to me,” she says. “Not only did I receive compassionate care from my wonderful therapist, I was treated with compassion by those around me – and the abundance of compassion I received helped me to recover.”

Kimberly Grady wrote Life at Grady: Stop, Look, Listen, posted on ACP Hospitalist. The patient presents with a fever and leg pain after a bad pedicure.

I immediately covered my mouth, forgetting that I was in earshot of my attending. Then I said it again as I skimmed the abstract of that article. The second time, I didn't even bother covering my mouth. This "damn" wasn't a "Damn, I should've known that!" It was a "Damn, this dude knew what was wrong with this patient just from the bedside." Or better yet "Damn, when I grow up, I'm TOTALLY going to roll up on a patient's bedside and nail a diagnosis just like that."

Ramona Bates from Suture for a Living tweeted her submission about The Impact of Obesity on Breast Surgery Complications, which she swears is a HOT topic in her field.

Overall, 18.3% of obese patients had a complication compared to only 2.2% in the control group (p<0.001). After adjusting for other variables, the researchers found obesity status increased the odds of experiencing a complication by 11.8 times.

Elaine Schattner from Medical Lessons emailed a related HOT topic from Wired, Human Milk for Sale, Where's the FDA?

As much as I think it’s a good idea for women to breast feed their babies as best they can, I was pretty shocked to learn about this unreg­u­lated industry. Mainly because if a woman who donates milk is infected with a virus, like HIV or HTLV-1, the milk often con­tains the virus. The infant can absorb the virus and become infected. Feeding human breast milk from an unknown donor is kind of like giving a child a blood trans­fusion from a stranger, unchecked by any blood bank.

Glenn Laffel from Pizaazz emailed The Effectiveness of Online Health Intervention Programs, talking about the HOT new trend of medical apps, particularly the online videogame, Re-Mission.

Re-Mission is intended improve medication compliance in teens and young adults with a history of cancer. In the game, players control a nanobot within a 3-dimensional body of a young person that has cancer. Play involves destroying cancer cells and managing chemotherapy-related adverse effects like vomiting and bacterial infections by using antiemetics and antibiotics. The game purports to help users understand their disease and its treatment and improve their sense of self-efficacy: they can take control of their disease.

And the last not-quite last submission, from Jessie Gruman of the Prepared Patient Forum, discusses a HOT topic in health care: Check-In-The-Box Medicine: Can the Blunt Instrument of Policy Shape Our Communications with Clinicians? 

I was impressed. This is what every pharmacy should be like – except, of course, for the dinginess, the creeping line and the fact that it was so crowded I could overhear these conversations. Maybe if we got federal legislation enacted requiring pharmacists to offer counseling with each prescription filled, this kind of attention would be the norm, adherence to medication regimens would improve and drug-related injuries would be reduced. Wait a minute. Someone already had that good idea.

[these last three posts were accidentally left out of the initial draft... sorry guys]

The Happy Hospitalist was thinking about how to explain those unwritten Bathroom Etiquette and Rules for Public Restroom to his young son [get it?].

• Always leave at least one urinal between you and another person
• Do not look at others while urinating
• No touching

Beth Gainer in Calling the Shots is a little steamed about the unintended fall-out from a National Cancer Survivors Day.

Just when the marketing of cancer feel-good gimmicks cannot get more insulting, there's National Cancer Survivors Day. Oops, I forgot to include that pesky little registered symbol.

Romeo Vitelli in Providentia sent in a radioactively hot post on the history of radium in That Healthy Glow.

By 1917, the United States Radium Corporation had patented the first glow-in-the-dark radium-based paint (with the brand name of Undark). Between 1917 and 1926, the company employed hundreds of female workers to paint luminous watch dials under uncontrolled conditions. The workers (later known as the Radium girls) had been reassured that radium-based paint was harmless and no industrial safeguards were in place to limit contamination. ... the factory managers encouraged the workers to use their lips and tongues to wipe off the paint. Some of the workers even went to far as to use Undark to paint their fingernails as an odd fashion statement. By the time the toxic consequences of radium exposure became apparent, it was far too late for them.

Okay, so that's the end of our Hot Grand Rounds. Do have a safe and healthy summer!  Be sure to check out next week's Grand Rounds host, Colorado Health Insurance Insider.




=Steve Daviss MD, co-author of Shrink Rap: Three Psychiatrists Explain Their Work.

Please Complain

For those who don't follow the comment sections of posts, there have been commenters who have been telling us about the awful experiences they have had as psychiatric patients.  In particular (but not exclusively) as  hospital inpatients.  Commenters have used terms like "abuse" and "humiliation" and describe awful scenarios.  One person asked why the mean nurses don't get fired, everyone knows they are mean including the staff.  Others throw the baby out with the bath water, one bad experience.  There is implication by at least one commenter that he/she would rather die (presumably permanently) rather than face a days on a psych unit again.  The suffering in these posts is palpable.

To those who feel better after leaving comments on Shrink Rap, by all means, feel free to continue, but this will not change the world.  May I put in a request?  If you've had an awful experience as a patient on a psychiatric unit, please tell the hospital.  One commenter said she (/he?) complained to the hospital administration and heard that some changes were made.  My thoughts?  You Go Girl!  (If the commenter was a male, I'm at a loss. Way to Go, Joe! perhaps?)  Complain, it can't hurt. 


Oh, you say, no one listens to psychiatric patients, they just say we're crazy so they don't have to listen.  For an isolated complaint, you may be right, especially if the complaint is about something that is not egregious.  But if everyone who feels wronged complains, then it won't be an isolated complaint, and I can tell you that for administrators, one person accusing is a fluke --or a psychiatric patient they don't need to listen to-- but at a very low threshold of two or three complaints, it quickly becomes "PEOPLE are complaining about such and such"  and someone starts to notice.  If the complaint is egregious (My nurse punched me) then a single complaint should have an impact.  

Who should complain?  If you were upset over something that happened and it continues to linger, you can't let it go, and you continue to feel angry, wronged, and injured, then you should complain.


So let me tell you how to complain.


1).  Call the hospital and ask where to direct a complaint and get a person's name and postal or email address.  Also send the same letter to the chairman of psychiatry, and the head of the hospital...why not?  Address the letters to specific people by name; "Dear Sir," "To Whom It May Concern,"  or "To the Sadist Creep on the Psych Unit" will not go far.
2).  Just the facts, ma'am.  Tell the administrators when you were hospitalized and that you continue to feel distress/angst/anger/whatever you feel about things that happened while you were in the hospital and give a bullet point list of the things that continue to trouble you.  Include specific examples, if you can, names of those who were involved.  If you don't recall specific examples, it still seems to me it's valid to say "Shrink John treated me in a harsh and disrespectful manner."   Say how you felt: "It was humiliating to be stripped and placed in a seclusion room." 
3).  This is not the time for name-calling,  hater rants,  or discussing the care of other patients.  "This is why everyone hates psychiatrists," "You people over-medicate everyone,"  Pretty much guarantees that the recipients shut down. Stick to your problem.  Be polite and respectful and try not to compare the mental health professionals who treated you to serial killers.
4) Sign your name and leave contact information.
5) Show it to a friend first and wait a day to send it.


I don't know if you'll get a response or a change, but if everyone who feels as wronged as our commenters do writes to complain, then things will change.  It may take time.  Don't be hater, be a changer.



Thank you for considering my suggestion.
Happy Father's Day to all, and remember to submit your Grand Rounds post now.