Do the Kids Do it Differently?

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

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

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

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

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

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

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

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

Life Without Parole, But With Health Care

The rising cost of prison health care is due mainly to the aging inmate population according to an article I saw on CNN recently. To me this really wasn't news; is it any surprise that older people have more medical problems? Or that the prison population as a whole is older due to longer sentences? Not really.

This story interested me because the Supreme Court is now considering the issue of life without parole for juveniles.  The idea is that juveniles can be rehabilitated and should be given a second chance, eventually.  

I can't help wondering if this issue is coming up now in part because prison officials, and inmate advocacy organizations, are starting to realize the full cost of a system filled with "lifers".  They need more than just medical care.  They need physical accomodation (and security accomodation) for wheelchairs, quad canes, braces, pumps and other medical devicies.  They need nursing care for feeding, dressing and bathing.  They need psychiatric care for dementia and other age-related psychiatric problems.  Eventually, they need hospice care.

Medical parole, also sometimes called "compassionate parole", is available in some systems. But this is sometimes dependent upon a terminal illness with a six month life expectancy. And it's not always granted if the inmate's offense was particularly notorious or horrific.

It's good to periodically examine our sentencing policies, but I get wary of any mandatory sentence that's based on a class of offenders rather than on the offense itself. Singling out people with mental disorders, juveniles, the developmentally disabled (and yes, women automatically get classified as 'vulnerable' and less culpable too) makes me uncomfortable. Banning life without parole for a juvenile, simply because he is a juvenile, negates a host of sentencing factors that a judge should be allowed to consider. These cases are challenging and difficult, and sentencing decisions are best left to an experienced judge who has access to all the information in a given case.

If life without parole is banned for juveniles, the next step logically would be to reconsider long sentences for older inmates.  Should someone who is fifty years old be given a 30 year sentence? Given that the average life expectancy for an American is 77 years, that's an automatic life sentence.  What about someone with cancer or HIV, someone with a potentially fatal illness who is not immediately dying? Should we base a sentence on five year survival rates? Otherwise, we are giving a life sentence, without parole. If you ban mandatory life for juveniles, you need to reconsider sentences that are the functional equivalent to mandatory life.

It gets complicated but hopefully these are the issues that the Supremes are going to be thinking about.

FDA & Social Media Hearing: #FDASM Word Cloud

Twitter was awash with thousands of tweets (click link to left to read them) the past few days regarding the FDA's hearing today and yesterday about regulation of pharmaceutical marketing on the internet and using social media. Above is the word cloud for the tweetstream on the topic (minus all the references to fdasm, fda, RT, bit.ly, http, etc).

If you want to dive deeper, check out the links on tr.im/hitlinks and on fdasm.com. A list of links to many of the presentations are available here. Public comments to the FDA are being accepted through Feb 28, so go to one of the above links to find the public comments page if you have something to say about this area. The controversies involve things like providing fair balance in 140 characters, making it easier to find plain English info on adverse effects, and whether the FDA rules about drug companies hunting down every mention of adverse effects should be revised based on the preponderance of user-generated content out there.

Shrink Rap: Grand Rounds is up at CRZEGRL (Veteran's Day theme)

The theme for crzegrl's Grand Rounds this week is Veteran's Day.

The shrinky links:

• doctors & mistakes (Medicine & Technology)
• pharma ads & claims on twitter (HealthBlawg) ... also follow #FDAsm on Thur & Fri for coverage of the FDA's anticipated hearing on social media and Web2.0 (links for live streaming on HITshrink)
• antidepressants for chronic pain (How to Cope with Pain)
• love in the recovery room (Anesthesioboist) ... not really shrinky, just beautiful

Sliding Fees

A lot of psychiatrists and other mental health professionals tell me they slide their fees, giving reduced rates to patients who can't otherwise afford to come. I want to ask: How do docs decide to do this? At clinics, scales are based on income (perhaps by family size), and just income, with a pre-set structure. But in private practice, this isn't usually the case (I don't think), and I wondered what other people do. In general, I've hesitated to slide my fees very much and this gets hard. Some of the patients I see live life without many luxuries-- rented homes, used cars, rare vacations. Sometimes it's a choice-- they choose not to work (when they could), and sometimes they are struggling quite hard to make ends meet, and yet they don't utter a word of concern about my fees. If anyone brings it up, it's me. Other times, patients are very verbal about their financial issues, how much they plan and calculate exactly what they can afford, and are very concerned about my fees and exactly what they can or can't afford. What's hard is that some of these same people are "strapped" because their life styles include many luxuries--boats, luxury cars, nice trips, a fine bottle of wine here or there, expensive tuitions, and maybe unexpected expenses. They come less then they should, or would like, because my fee is high. Maybe they've bitten off more then they should have (especially in the current economy) and are going through bankruptcy proceedings, or are simply worried about what the future might bring. Being tight on funds and the perception of what one can afford is based on many things, and so I'm putting this out not to get my own answers, but to ask how other people deal with this? Years ago I had a friend who was seeing a patient at a greatly reduced fee, only to discover that he lived in a much nicer house then she could afford-- it put some tension into the therapeutic relationship, I'm sure.

I Am Not 'One Of Them'

Since the Fort Hood shooting I've been hearing and reading a lot in the media about 'compassion fatigue' and 'vicarious trauma'. I feel compelled to blog after reading yesterday's New York Times article on the topic, which I'm sure won't be the last.

The idea is that any mental health professional who spends their days listening to patients tell their stories of traumatic events will eventually end up having emotional difficulties from it as well. The other term for this is 'compassion fatigue', in other words losing the ability to empathize with others or becoming numb to trauma due to exposure to patients' traumatic stories. The Times article is careful to point out that vicarious trauma and compassion fatigue will not automatically lead one to become a killer.

Well, I'm relieved to hear that.

Over the years as both a forensic and correctional psychiatrist I've heard plenty of trauma-related stories. I've reviewed autopsy photos and crime scene photos and read police reports of violent offenses and watched videotapes of violent offenses. I've heard people talk about
their crimes and talked to victims of violent crimes (if they survived). People who have read my "What I Learned" posts know that the annual conference of the American Academy of Psychiatry and Law regularly features presentations about serial murderers, psychotic killers, crime scene investigation techniques and other topics that can be a bit gruesome.

If all 1700 forensic psychiatrists in this country are exposed to this regularly that's a whole lot of vicarious trauma. It's good to know I won't automatically become a spree killer.

Frankly, I wasn't worried.

Ch-Ch-Ch-Changes!

The times they are a-changing....

Next year, the new parity laws for mental health will go into effect: health insurance must cover mental disorders the same when it covers other medical illnesses, without limits on visits, or higher co-pays. It remains to be seen how this will play out-- my fear has been that the response might be to simply eliminate mental health benefits from insurance policies. From the American Psychological Association (sorry, it was a pdf file so there is not a direct link) on the Wellstone-Domenici Parity Act of 2008 :

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (The “Wellstone-Domenici Parity Act”) will end health insurance benefits inequity between mental health/substance use disorders and medical/surgical benefits for group health plans with more than 50 employees. Under this new law a group health plan of 50 or more employees that provides both physical and mental health/ substance use benefits must ensure that all financial requirements and treatment limitations applicable to mental health/substance use disorder benefits are no more restrictive than those requirements and limitations placed on physical benefits. This means that equity in coverage will apply to all financial requirements, including lifetime and annual dollar limits, deductibles, copayments, coinsurance, and out-of-pocket expenses, and to all treatment limitations, including frequency of treatment, number of visits, days of coverage and other similar limits.

We don't know yet how this will play out...I hate that little clause "...that provides both physical and mental health/substance use benefits..." because it's left as an option. Would we tolerate a health insurance plan that excluded pneumonia or cancer? And it would be so nice if one could see a psychiatrist without pre-authorization (do you need pre-authorization to go to the doctor for your back pain or headaches or fever?) but my guess is that won't play out, since surgeries require pre-approval in many plans.

The New York Times has an optimistic piece on upcoming parity. Leslie Alderman writes in "In Anxious Times: Help for the Mind as Well as the Body:" Alderman writes:

The law’s changes can be good and not so good. Good, because you might have access to more care. Not so good if there are new requirements, like getting precertification for coverage, that place additional barriers to getting treatment, says Kaye Pestaina, vice president of health care compliance for the Segal Company, a benefits consulting firm.

“Employees should make sure their employer provides information to them about any new medical management rules,” Ms. Pestaina said.

Okay, so the House just passed the President's Health Care Reform bill (all 1,990 pages of it). What might this mean for psychiatry and how will parity play out in a newly-insured American?

One Of Us: Physicians Who Kill

"I have already said that if you kill a doctor, all the doctors are instantly on your neck. But what if the man who does the killing is a physician himself? That complicates the situation most damnably..."

---Foursquare: The Story of a Fourfold Life by John Oliver

I've been reading, along with everybody else, the story of the Army major and psychiatrist Dr. Nidal Hasan who killed thirteen people in a spree shooting at Fort Hood yesterday. Let me say first that I've never met Dr. Hasan and know nothing about him; I have no particular information or insights about this offense beyond what I've read in the media.

The CNN article today interviewed two of Dr. Hasan's patients, who both said nothing but glowing things about him and his care. I've blogged about spree killers before ("Shooter Psychology") but this case is different. It got my thinking about the general issue of physicians who kill.

Physician killers are certainly a relative rarity, but they are not unknown. Dr. Jack Kevorkian is probably the most famous here in the United States, but in the United Kingdom there was the case of Dr. Harold Shipman. Dr. Shipman forged the will of, and then killed, several elderly female patients. Then there was Michael Swango, a serial poisoner who killed his patients specifically so that he could take credit for his heroic "resuscitation" efforts. As far back as 1920 Dr. John Oliver wrote about an anonymous psychiatrist colleague who killed another physician and was found legally insane. The quote at the start of this post is from Dr. Oliver's autobiography were he discussed the case. For anyone really fascinated by the topic, I refer you to the book Demon Doctors: Physician Serial Killers. I haven't read it myself so I can't vouch for it; feel free to write in reviews.

But I digress. Getting back to what happened at Fort Hood, the news reports don't indicate anything to suggest that Dr. Hasan was psychotic, motivated by greed or financial gain or out of a need to be a hero. He wasn't an infantryman who had been exposed to combat and who might have been terrified of going back to a traumatic environment. He was educated and presumably in a better financial and social situation than most of the patients he treated, unlike many of my murderer patients who have burned multiple social bridges prior to the killing.

Regardless, a killing by a physician---particularly by a psychiatrist---creates a bizarre aftermath. The military is sending mental health professionals to counsel the victims and witnesses; I'd be willing to bet those military mental health professionals will be required to check their weapons at the door.

Here is an excellent article about preparing for testimony, for anyone
who has to testify at civil commitment hearings:

http://www.currentpsychiatry.com/article_pages.asp?AID=8091

One Offender's Story: Not Sick Enough

I don't blog about patients, so I was pleased to find this excellent story about one mentally ill offender covered by American RadioWorks. I don't know and have never met this prisoner, but his story is similar to many of those I evaluate and treat.

 

http://americanradioworks.publicradio.org/features/mentally_ill/stories/notsick1.html

Too Interesting For Twitter

I had to put this up on the blog because it was just too quirky to Tweet. A prisoner in the U.K. filed suit to request visitation rights for his cat:

Cat Banned From Visiting

The Accessible Psychiatry Project

We've decided we could use an umbrella organization to explain what we do in a more official capacity. What do you think? And yes, the podcast will be back, we're just trying to keep our heads above water with getting the manuscript done for the book, blogging, and the rest of life!
----------------------

The Accessible Psychiatry Project

Encouraging dialogue about psychiatry across media.

Mission Statement:

The Accessible Psychiatry Project strives to encourage dialogue about psychiatric disorders and their treatment in order to explore issues of controversy and misunderstanding in our field. Through open dialogue, in both new media and old, we hope to foster awareness about the work psychiatrists do, and to decrease stigma associated with the treatment of mental disorders.

Components of The Accessible Psychiatry Project include:

Shrink Rap: a blog by psychiatrists, for psychiatrists. April, 2006- present—currently over 1100 posts on a wide variety of mental health topics.

Shrink Rap: http://psychiatrist-blog.blogspot.com/

Shrink Rap gets approximately 2,000 unique visitors per week. Readers are not limited to psychiatrists

My Three Shrinks podcast: a regularly aired show featuring 3 psychiatrists. Other mental health professionals have made guest appearances.

My Three Shrinks: http://MyThreeShrinks.com/

November, 2006- present, 48 episodes aired,

10,000 downloads/month

Featured on the Itunes Medical Podcasts Webpage

ShrinkRapRoy Twitters about technology and healthcare.

ClinkShrink Twitters about issues related to psychiatry and the law.

Off the Couch: Three Psychiatrists Discuss Their Work. In process, to be published by Johns Hopkins University Press, 2011.

What I Learned Part 4

I attended a great lecture on the history of forensic psychiatry.
Prior to 1825 most forensic experts were providing testimony on
relatives or former patients. There was a woman who tried to kill King
George III and was found insane. Benjamin Rush promoted the use of the
"tranquilizing chair".

Homeland Security is moving into the old St. Elizabeth's Hospital.
There's something weirdly appropriate about them being in a
psychiatric facility. James Hadfield killed another patient and later
escaped but was recaptured. Edward Oxford tried to kill Queen Victoria
and was found insane. He was ultimately discharged from the hospital
and immigrated to Australia.

It's estimated that there are150 victims of Munchausen's by proxy
every year. Most victims are under the age of five.

A surprising number of surgeons have performed their own procedures
including appendectomies and herniorhaphies.

Rethinking Antidepressants

Thanks to Henry for sending this link.

On cnet news, Elizabeth Armstrong Moore writes about research presented at this month's Neuroscience conference in Chicago:

Depression researcher Eva Redei presented research at the Neuroscience 2009 conference in Chicago this week that calls into question two tenets of depression science: that stressful life events are a major cause of depression, and that an imbalance in neurotransmitters triggers depressive symptoms.

Armstrong goes on to report that the research looks at the overlap of genes in RATS (not peeps) and notes that antidepressants work better for stress then depression and the genetic overlap between the two is minimal (--oh, why isn't Roy writing this, he's so much more eloquent than I am about the genetic stuff).
Armstrong goes on to say:

To test the long-held belief that stress is a major cause of depression, Redei looked for similarities between these two sets of genes. Out of more than 30,000 genes on the microarray, 254 were related to stress and 1,275 to depression. Only 5 were found in both samples.

"This finding is clear evidence that at least in an animal model, chronic stress does not cause the same molecular changes that depression does," Redei says. She is now looking at the genes that differ in the depressed rats so that she can narrow down targets for drug development.

Antidepressants are also often ineffective, Redei says, because they aim to boost the neurotransmitters serotonin, norepinephrine, and dopamine, whose reduced levels have been associated with depression. But this strategy is now also being called into question.

It's sort of news to me that we thought stress "causes" depression. I guess I thought extreme stressors (as opposed to general 'stress') can precipitate depression in those inclined to become depressed. Many people suffer extreme distress without getting major depression and many people with histories of major depression weather severe storms without a recurrence. What is nice about this research is that it challenges us to think in new ways, and I think sometimes research gets hooked around theories that aren't definitely proven and creativity gets stifled. Anything that nudges that can't be bad....