Boarding Psych Patients in the ER

It's no secret that over time, the number of available beds in psychiatric hospitals and on psych units of general hospitals have decreased.  When the states moved patients from long term beds in state hospitals back into the community (a mostly good thing if you ask me), the promise was for more services in the community, and oops, that never came to be.  With time, there are fewer and fewer services available, it's harder to get care with people often waiting weeks to be added to the overburdened caseloads of staff in outpatient mental health centers -- especially those who have no insurance or Medicaid/Medicare -- meaning the people most likely to have the biggest problems seem to have to wait the longest.  If you need help now, there's often only one answer: go to the Emergency Room.  

This is thing about going to the ER.  They often have no miracles.  In the hospital where I worked in the clinic, there were a few perks -- the ER had some reserved clinic slots so that they could refer people for outpatient appointments within a few days.  Often, however, this isn't the case, and often delaying treatment means that the situation is so bad that the patient needs to be admitted. Because I was at a facility with 84 psych beds, this generally happened fairly quickly, but it many places, this just isn't the case.  People can wait for beds for hours (okay, that's life in an ER), days (ugh) or even weeks.  Weeks?  A psychiatrist in Vermont (where the state hospital had been destroyed in a hurricane) told me they kept patients in the ER for 6 weeks.  Six Weeks.  I have no idea how they did that and I didn't ask.  Did the patient stay in a seclusion room?  What if the room was needed for another aggressive patient?  Did they get a cubical? A gurney in the hall?  A curtained area?  Most psychiatric hospitalizations last about 7-12 days.  Were they getting medications and therapy in the ER?  This is crazy, and I use that term to describe the insanity of our system, not the patients.

This summer, the Department of Health and Mental Hygiene here in Maryland held work groups to discuss the delivery of outpatient care and recommendations for legislation for outpatient civil commitment -- we are one of only 5 states that has no provision for mandating outpatient treatment.  The work groups were ordered by the state legislature.  I went to some, and at one, an ER physician (not a psychiatrist) made a comment that sometimes patient were held in the ER for days "and they describe those days as the worst days of their lives."  This just shouldn't be -- no hospital experience should be horrible because of the setting --granted, it may be horrible if you're in the middle of a panic attack, a heart attack, you've just been shot, or you've lost a limb --but it should be a place to be stabilized, then discharged or admitted, without physical discomfort.  

This was my long-winded way of pointing you to an article in Forbes about ER psych boarding.  Do read: "Boarding" of Psychiatric Patients Unconstitutional in Washington State by Robert Glatter, M.D.  Glatter writes:

In Washington, patients who are involuntarily committed must be brought before a judge after 72 hours. The judge then makes a decision whether to continue to detain the patient in the emergency department.  Some of these patients may then be returned to the same ED.
Such patients may remain in less than ideal locations such as hallways, administered psychiatric medications, but having no formal access to psychiatric evaluation and care. Staff members including nurses and administrative staff have in some cases faced verbal or physical threats from such patients, with their safety being a concern.

The ruling leads to some obvious concerns:

“While we respect the state court’s decision, federal law (Emergency Medicine Treatment and Labor Act) still prevents hospital emergency departments from discharging unstable patients — for example suicidal or homicidal patients — back into environments where they could cause harm to themselves or to others.  This ruling does not provide guidance for hospitals and physicians regarding resolution of the conflicts among federal law, this state ruling, and the medical liability risk of discharging patients based on a time limit rather than based on reaching a stable condition,” added Rosenau.
“The ruling is a call to action, and our main objective must be to get every patient the right level of care.  The next challenge is directed to hospital and community leaders to find the resources to care for them,” concluded Rosenau.

Glatter goes on to discuss some possible solutions: better outpatient services, case management, crisis beds and mobile crisis units, more beds, and elimination of out-of-network barriers that keep some patients out of some available beds.  All good ideas.  

Have You Ever Called The National Suicide Prevention Hotline?

After Robin Williams died, my Facebook feed was full of ads for the National Suicide Prevention Hotline.  There's a reason for this: when celebrities commit suicide there may be an increase in suicide, copycat acts if you will.  Publicizing means for help does help -- after Kurt Cobain's death, calls to such centers went up and suicide deaths went down.  

I'd like to write about what happens when people call suicide prevention hotlines.  If you have, will you tell me your story?  Or if you work for one, I'd love to hear about your experience.  To write, I  may need to be able to contact you (I don't need to publish your name), so perhaps an email rather then a comment?  Shrinkrapblog at gmail dot com.

Be safe and thank you!

The Shrink in the Shrink Rap Tie and Links to Interesting Articles.

So I'm at work today, seeing patients, and I get a text.  Between patients, I check the phone and there in the body of the text message is a photo of a man I've never seen and he's wearing a duck tie.  The text is from a beloved friend who is a doctor (not a psychiatrist) in another state.  The photo is of the psychiatrist in their medical facility, he's come to work in a duck tie.  As it would happen, it's pure coincidence; he's never heard of Shrink Rap and has no clue that it's our blog motto, but this dear psychiatrist allowed my friend to photograph him and text me his picture, and consented to having his tie on our blog, provided we don't violate HIPAA for any of the ducks.  In case you wondered what your doctor is doing all day, he may be texting photos of ducks to his friends.  

With that as an opener, there have been lots of interesting psychiatry articles on the web.  Let me give you teasers and links:

The Boston Globe has been running a three-part series on their front page about a man with a severe psychotic illness and how it has devastated him and his family.  A reporter followed the family for 18 months, do check it out here.

And while we're talking about the broken mental health system, Dr. Paul Appelbaum has some suggestions for how to fix it in The Guardian.  You can check that out Here.  

And while The Guardian is writing about the broken mental health system in the US, The Economist is writing about the broken mental health system in the UK.  You can read about that Here.  

Scientific American tackles the tough question of whether you should tell your boss you have a mental illness Here.   

Here's a story I liked about a police officer who risked his life to pull a man off a bridge.  We need a good cop story once in while, and they come few and far between in the media these days. 

Here's another police article in The Atlantic about the helpfulness of police Crisis Intervention Teams in San Antonio, and the importance of training the police to understand and help people with psychiatric disorders.  These teams decrease the number of people who end up being killed by police.  

Our Hopkins colleague Dr. Kay Jamison had a op-ed piece in the New York Times on the difficulties of treating depression and how it's important that the psychiatrist be competent, check that out HERE. 

In another moving op-ed piece in the NY Times, Roger Cohen talks about his search to understand his mother's struggle with depression HERE.   

There's been a lot of psychiatry articles in the popular press.  This is just a few, but I do often tweet them when they come out, so do feel free to follow my twitter feed @shrinkrapdinah.


 

How Hard Is It To Find a Psychiatrist? Tell me your stories!

One of the concerns I have about funneling our resources into programs for involuntary treatment is that I believe it's difficult for those who want help to get it.  Some assume that those who don't recognize their need for help are society's sickest patients, and that resources should go to them first.  So I want to hear your stories of looking for a psychiatrist.

So let me ask you, how hard is to find a psychiatrist here in the United States?  If you found one easily --- say a morning's worth of phone calls and appointment within a reasonable time -- just say "Easy" and please tell me what part of the country you live in and if you live in an urban/suburban/rural area.  If you had a longer story, I'd love to hear that as well, with the same demographics.

Thanks so much!

Looking for People to Talk to Me about Involuntary Electroconvulsive Therapy (ECT or "shock" treatments)

As our regular readers may know, we are working on a book called Committed: The Battle Over Forced Psychiatric Care.  In Maryland, there is no provision for people to have ECT against their will, it's a voluntary procedure and someone else can't sign you up.  Before I learned about it from Shrink Rap readers, I didn't realize that there are other states where ECT can be court-ordered and done against a patient's will. 

I'm interested in talking to people about their experiences with involuntary ECT.  Anyone with a personal story is invited -- patients who've had it (court-ordered, not cases where people have been cajoled into voluntary treatment), but also family members, doctors, nurses, and the staff who do it, and even the judges who order it.  

I can be reached at email : shrinkrapblog at gmail dot com, by writing a comment on this post, or via Twitter @Shrinkrapdinah.  If you have no personal connection to forced ECT, please don't comment.  I do already know that many people think it's awful. 

What Happens When Patients Won't Take Meds?

You're here reading Shrink Rap, so you may think this is a post about patients who refuse to take psychiatric medications, and non-compliance with psychiatric medications gets to be it's own issue.  So it caught my attention when Dr. Albert Fuchs tweeted that he was interviewed by NPR about "What happens when patients won't take medicines."  Dr. Fuchs is a primary care doc with a concierge practice in Beverly Hills, so I wanted to hear what he had to say, and I invested 6 minutes of my life in listening to his NPR talk -- you may want to go to the website and listen as well.  He makes a good point about being cautious when an addictive medication is prescribe, and he notes that in Los Angeles people are pro-health, anti-medication and perhaps that skews who he sees, but that medication refusal is common.  I'm thinking that by the time you're paying an outrageous concierge fee to your primary care doc that either you're ill and  feel you need extra attention or money's not an issue in your life -- after all it's Beverly Hills.  But my other thought is why would someone invest in this type of care if they are not going to follow the doctor's suggestions?  If you're going to blow your doc off, do it when there's a $20 co-pay.  

That said, I'm not exactly the best of patients, and I've had a doctor who has wanted me to take calcium supplements for years.  She is insistent.  One look at me and one thing is clear: I'm well nourished.  I don't think I need supplements, I think I get plenty of everything in my diet, and a close friend started taking calcium on the advise of her doctor and promptly got a kidney stone, and the literature suggests that dietary calcium is better than supplements, at least for people in some demographics .  I assure my doctor that I ingest enough calcium. She's asked me what I eat, to which I've replied milk, yogurt, cheese, and ice cream.  "Do you eat ice cream everyday?"  Isn't that harassment?  Of course I don't eat ice cream every day, but I wish I did.  I surrendered, I bought a bottle of Tums and a few times a year, I eat one.  This way, when I see this doc, I can say with impunity that I sometimes take Tums and this seems to stop the conversation.  Maybe I'm wrong and someday I'll have brittle bones and wish I had listened and taken calcium supplements.  So I have mixed feelings about whether one always needs to follow doctors' orders exactly and under what circumstances.  Certainly the issue in psychiatry gets very complex if the patient is psychotic and  repeatedly decides not to take medications and keeps ending up in the hospital or puts himself or others at risk.  

 In the meantime, my favorite flavor, for anyone who wishes to buy me ice cream, is praline pecan. 

Suicide: A permanent answer to a temporary problem. Rest in peace, Robin Williams.

The news last night was tragic, Robin Williams has died of an apparent suicide of the early age of 63.  I saw the news and felt overwhelmingly sad.  Really?  He was a tremendous actor, a creative genius by any account, a man who I imagined had everything -- talent, wealth, fame, the wonderful ability to make people laugh and to brighten lives. Such people also get draped with love and admiration, though certainly at a price.   For what it's worth, Robin Williams has been open about the fact that he's struggled with both depression and addiction, but the complete story is never the one that gets told by the media.

Twitter started with 140 character links to Suicide Hotlines and suicide awareness, to statements about how depression is a treatable illness -- Is it always? -- and I hit re-tweet on a comment stating "We’re never going to get anywhere till we take seriously that depression is an illness, not a weakness" and several people retweeted my retweet.  I'm not sure why I did this; I don't think that most people still think of mood disorders as a "weakness," or that those who do might change their minds because of a tweet.  And I don't think that suicide does anything to reduce stigma.

One shrink friend tweeted a comment about how one should never ask someone why they are depressed, I guess because the "why?" implies something other than because biology dictated it, but if you've ever spoken to a person suffering from depression, you know that it comes in all shades of severity and that people often write a story to explain it.  Sometimes that story is right -- I'm depressed because of a break up, or because I don't have a job now, or because of on-going work stress -- and indeed, the person suffering often feels better after talking about the situation, after getting a new boyfriend or a new job, or after their boss moves to Zimbabwe.  I'm convinced that treatment works best when psychotherapy is combined with medication (if indicated) and while medicines are a miracle for some, they aren't for others.  As psychiatrists, we certainly see a good deal of treatment-resistant depression.  And yes, the anti-psychiatry faction may postulate that it is the treatment -- the medications, specifically - that cause people to kill themselves and others, but I will leave you with the idea that the science just doesn't support that.  Certainly, they aren't for everyone, but clinically I have seen medications do more good than harm in clinical practice overall. Please don't send comments about how treatment kills, I won't be publishing them. 

I know nothing about Robin Williams beyond what I've read in the media, and I know that the media presents it's own version of what happened.  I do imagine that Mr. Williams had the resources to get good care and that he may well have had treatment for depression since he was open about his struggle.  His story will be used to say "Get Help" and if you're feeling suicidal and aren't getting help, please do.  If you're feeling suicidal and "help" isn't making you feel better, please consider getting a second opinion or a different kind of help.  

The tragic thing about suicide is that it's a permanent answer to what is often a temporary problem.  People commit suicide for a variety of reasons -- unbearable psychic pain of the type that comes with Major Depression or Bipolar Disorder or any other psychiatric disorder, being just one reason.  Being in a bind (financial, love, legal) that one can't think of a way out of is another.  And tragically, on an impulse, with the barrier lowered by drugs or alcohol.  The truth is that when psychic pain --from depression or grief or heartbreak or anything else-- is bad, intoxication offers a quick relief for a fleeting moment, and when that moment of relief passes, a person's mood often drops violently and then suicide offers another way out, with the usual obstacles removed by the intoxicant.  If you're feeling sad, don't drink or use drugs to alleviate the pain, and if you must, don't do it alone and don't do it where there is easy access to a lethal means of ending your life.  

Sometimes, I imagine that there are people who have tried and tried to get help and that their pain remains so unbearable for so long that suicide offers them the only possible relief -- if such a thing is even to be had given that we don't what comes next and some religions will say that suicide leads to nowhere good.  Even if it provides relief to the person involved, it comes with the cost of leaving those who remain in horrible pain.  Sadly, depressed people sometimes imagine that the world will be better off without them, and often that idea is just not true. 

I hope that Robin Williams is in a better place, for his sake.  I hope that before he ended his life, he tried every possible treatment option, and that this wasn't an impulsive decision, or one based on an episodic relapse of either depression or substance abuse -- a relapse that may have resolved and let him live for decades more.  I hope his wife and children and all the people who knew and loved him will eventually find some peace.  His death, however, is not simply a personal one because he touched us all with his talent and his charisma.  What a tragic loss. 

Is "Shrink" offensive? Take a one-question poll!

Over on Clinical Psychiatry News, we had a reader complain about our column title --Shrink Rap News.  He felt it was odd and offensive to use the term Shrink when people have worked so hard to reduce stigma.  I countered with the article there called "The Stigma of Being a Shrink" to discuss how we came to the title Shrink Rap for our work, and that the term "shrink" just didn't strike me as one which would alter care for our patients or leave us being seen in a negative light.  It's been 8 years of Shrink Rap -- the name has worked for us in the form of 3 blogs and a book, and well, shrink is one syllable while psychiatrist is 4 and psychiatrist does not lend itself to any cute puns or double meanings.  We're also not the only Shrink Rap or Shrink Wrap or Shrink Wrapped.  

So I thought I'd ask you: Is the term Shrink offensive?  Does using it alter the care our patients receive?  Should it be abolished from the jargon the way we no longer  use terms such as Lunatic?  Or the way we might like to get rid of words such as Crazy?  

I'm against stigmatizing people because of all sorts of things -- mental illness is only one of them.  I don't think anyone wants to be obese or have a drug or alcohol addiction, but some members of society seems to be okay stigmatizing those folks (--they could eat less and avoid their substances, apparently, if only they so chose...).  Calling a professional a 'shrink' -- I want to say "lighten up,"  but I'm all ears.  Not promising to change our blog name by any means, but what do you think?

And while we're talking about stigma -- there was a terrific article by Allen Frances over on the Huffington Post.  He notes, "Never has there been less stigma for having mild psychiatric problems, but never has there been more stigma for having severe ones." 

Sectioned -- on involuntary treatment in the U.K.

In America, people enter the hospital involuntarily in a process known as civil commitment.  On the other side of the pond, in Great Britain, it's known as being "sectioned."

My thanks to Mental Health @sectioned_ on Twitter who linked to this BBC radio program called "Shrink Wrapped" (not, not, not Shrink Rap) and a one-hour show on being Sectioned -- they interview a psychiatrist, a patient who has been sectioned roughly 10 times, and the police.  Here's the Link if you'd like to listen.  The issues sound to be the same on both sides of the Atlantic Ocean.  If you'd like to listen, it may only be available for a few more days.

The Creative Brain : Links to Mental Illness?

If you're a psychiatrist, you likely know who Nancy Andreasen is.  For as long as I've been around, she's been one of those big names in psychiatry and someone who leaves you to wonder if she ever sleeps, or if she has a clone, because it's hard to imagine that one human being can accomplish so much.  She has a Ph.D in English literature, and she's a psychiatric researcher who studies schizophrenia, neuroimaging, genomics and schizophrenia, and she directs every organization she belongs to and has won more prizes than I care to mention. She's a former editor of The American Journal of Psychiatry, the Chair of the University of Iowa's department of psychiatry.  In addition, she writes books, and scuba dives.  And yes, she's married with children.  I've heard her speak, and I enjoyed her recent article in The Atlantic, "The Secrets of the Creative Brain" enough that I read it twice so I could share the highlights with Shrink Rap readers. 

First, Dr. Andreasen talks about Kurt Vonnegut -- his depression and his strong family history of mental illness.  You may recall that I reviewed his son's book on Shrink Rap, "Just like someone with mental illness only more so."  Vonnegut's mother committed suicide, other family members suffered from mental illness, but they are also a very creative family.  Andreasen notes:

For many of my subjects from that first study—all writers associated with the Iowa Writers’ Workshop—mental illness and creativity went hand in hand. This link is not surprising. The archetype of the mad genius dates back to at least classical times, when Aristotle noted, “Those who have been eminent in philosophy, politics, poetry, and the arts have all had tendencies toward melancholia.”

She mingles talk about the course of her work and her dual career (literature, then psychiatry) with a discussion of her interest in mental illness and creativity.  Andreasen goes on to talk about the work of Stanford research Lewis Terman who identified and followed people with notably high IQ's over time.  She writes:

  For example, they were generally physically superior to a comparison group—taller, healthier, more athletic. Myopia (no surprise) was the only physical deficit. They were also more socially mature and generally better adjusted. And these positive patterns persisted as the children grew into adulthood. They tended to have happy marriages and high salaries. So much for the concept of “early ripe and early rotten,” a common assumption when Terman was growing up.

But despite the implications of the title Genetic Studies of Genius, the Termites’ high IQs did not predict high levels of creative achievement later in life. Only a few made significant creative contributions to society; none appear to have demonstrated extremely high creativity levels of the sort recognized by major awards, such as the Nobel Prize. (Interestingly, William Shockley, who was a 12-year-old Palo Alto resident in 1922, somehow failed to make the cut for the study, even though he would go on to share a Nobel Prize in physics for the invention of the transistor.) Thirty percent of the men and 33 percent of the women did not even graduate from college. A surprising number of subjects pursued humble occupations, such as semiskilled trades or clerical positions. As the study evolved over the years, the term gifted was substituted for genius. Although many people continue to equate intelligence with genius, a crucial conclusion from Terman’s study is that having a high IQ is not equivalent to being highly creative.

 Andreasen notes that 'creative geniuses' are generally smart, but don't have to be all that smart.  She seems to indicate that an IQ of 120 will do.  She talks about how to measure creativity with a test -- and defines convergent and divergent thinking, but then notes that this may not really be a way to measure creative genius.  Instead she settles on the Duck Test, and here at Shrink Rap, we like all things ducky, so I'll quote her on this one: 

A second approach to defining creativity is the “duck test”: if it walks like a duck and quacks like a duck, it must be a duck. This approach usually involves selecting a group of people—writers, visual artists, musicians, inventors, business innovators, scientists—who have been recognized for some kind of creative achievement, usually through the awarding of major prizes (the Nobel, the Pulitzer, and so forth). Because this approach focuses on people whose widely recognized creativity sets them apart from the general population, it is sometimes referred to as the study of “big C.” The problem with this approach is its inherent subjectivity. What does it mean, for example, to have “created” something? Can creativity in the arts be equated with creativity in the sciences or in business, or should such groups be studied separately? For that matter, should science or business innovation be considered creative at all?

Andreasen began to study people from the Iowa writer's workshop and people she deemed to be creative geniuses.  At first, she hypothesized that they would have more relatives with schizophrenia than the average person and she based this on her observation that some geniuses (e.g. Einstein) had relatives with schizophrenia.  

As I began interviewing my subjects, I soon realized that I would not be confirming my schizophrenia hypothesis. If I had paid more attention to Sylvia Plath and Robert Lowell, who both suffered from what we today call mood disorder, and less to James Joyce and Bertrand Russell, I might have foreseen this. One after another, my writer subjects came to my office and spent three or four hours pouring out the stories of their struggles with mood disorder—mostly depression, but occasionally bipolar disorder. A full 80 percent of them had had some kind of mood disturbance at some time in their lives, compared with just 30 percent of the control group—only slightly less than an age-matched group in the general population. (At first I had been surprised that nearly all the writers I approached would so eagerly agree to participate in a study with a young and unknown assistant professor—but I quickly came to understand why they were so interested in talking to a psychiatrist.) The Vonneguts turned out to be representative of the writers’ families, in which both mood disorder and creativity were overrepresented—as with the Vonneguts, some of the creative relatives were writers, but others were dancers, visual artists, chemists, architects, or mathematicians. This is consistent with what some other studies have found.

Andreasen became interested in using MRI to study the brain structure of people with schizophrenia (she is a pioneer in this field).  She began to wonder what imagining studies might reveal about the brains of the very creative.  

Designing neuroimaging studies, however, is exceedingly tricky. Capturing human mental processes can be like capturing quicksilver. The brain has as many neurons as there are stars in the Milky Way, each connected to other neurons by billions of spines, which contain synapses that change continuously depending on what the neurons have recently learned. Capturing brain activity using imaging technology inevitably leads to oversimplifications, as sometimes evidenced by news reports that an investigator has found the location of something—love, guilt, decision making—in a single region of the brain.
And what are we even looking for when we search for evidence of “creativity” in the brain? Although we have a definition of creativity that many people accept—the ability to produce something that is novel or original and useful or adaptive—achieving that “something” is part of a complex process, one often depicted as an “aha” or “eureka” experience.

She then goes on to talk about using PET scans to look at the workings of the brain when people are asked to think about specific "episodic" events versus free-associating or REST (random episodic silent thought).

Based on my interviews with the creative subjects in my workshop study, and from additional conversations with artists, I knew that such unconscious processes are an important component of creativity....In my own version of a eureka moment, the answer finally came to me: creative people are better at recognizing relationships, making associations and connections, and seeing things in an original way—seeing things that others cannot see. To test this capacity, I needed to study the regions of the brain that go crazy when you let your thoughts wander.

Her subjects spend 3 days in Iowa.  During this time, Dr. Andreasen has them to dinner at her house, drives them around her 40 acre nature retreat, then she interviews them (in-depth inquiries about their childhood, interests, families and more) and she scans their brains.  It sounds like fun.  I don't know if the control group gets dinner and the estate tour or not, but I'll assume so. She's studied 13 creative people and 13 controls.  Of the 13 creative types, 2 had parents who died of suicide (an exceedingly high number).

The creative subjects and their relatives have a higher rate of mental illness than the controls and their relatives do (though not as high a rate as I found in the first study), with the frequency being fairly even across the artists and the scientists. The most-common diagnoses include bipolar disorder, depression, anxiety or panic disorder, and alcoholism. I’ve also found some evidence supporting my early hypothesis that exceptionally creative people are more likely than control subjects to have one or more first-degree relatives with schizophrenia.

 Andreasen speculates about why the creative geniuses may have a higher incidence of mental illness:

One possible contributory factor is a personality style shared by many of my creative subjects. These subjects are adventuresome and exploratory. They take risks. Particularly in science, the best work tends to occur in new frontiers. (As a popular saying among scientists goes: “When you work at the cutting edge, you are likely to bleed.”) They have to confront doubt and rejection. And yet they have to persist in spite of that, because they believe strongly in the value of what they do. This can lead to psychic pain, which may manifest itself as depression or anxiety, or lead people to attempt to reduce their discomfort by turning to pain relievers such as alcohol.

Her subjects talk about the joy they get from creating, and she notes that they work much harder than other people, because they love their work.   Finally, in linking creative genius to mental illness, Andreasen ends with a mind-boggling thought:

Some people see things others cannot, and they are right, and we call them creative geniuses. Some people see things others cannot, and they are wrong, and we call them mentally ill.

 


   

Of Guns and Ducks

Around the web, I thought I'd point out some interesting stories:

 

A federal court upheld the legality of a Florida law which forbids doctors to discuss gun ownership with patients. The law, passed in 2011, was challenged as being a violation of a doctor's right to free speech.  Apparently, the second amendment is more important than the first amendment.  Why stop at gun ownership, perhaps every aspect of medical care should be legislated?  What right does my doctor have to pester me about whether I smoke or how much I drink or whether or not I'm getting enough calcium?  From the StarTribune:

The ruling by the 11th U.S. Circuit Court of Appeals in Atlanta overturned a previous decision that had declared the law unconstitutional. An injunction blocking enforcement of the law is still in effect, however.
The 2011 law, which had become popularly known as "Docs vs. Glocks," was challenged by organizations representing 11,000 state health providers, including the Florida chapters of the American Academy of Pediatrics and the American Academy of Family Physicians
Doctors who break the law could potentially be fined and lose their licenses.

The issue of boundaries in psychiatry is always a sticky one, and there are times when it seems prudent to bend some of the usual boundaries by a bit.  Still, I tell students, readers, anyone who asks me, that the two rules one should never violate: Don't sleep with or kill you patients.  Hmmm, this is a tragic story, but as the media is reporting it, a psychiatrist in a Philadelphia suburb pulled out his own gun and fired on a patient who had already shot at him and had killed his case manager.  Read the NY Times account Here.  The details are still unwinding.

And on to ducks:

Iraq veteran Darin Welker, pictured above, suffers from pain, depression, and post-traumatic stress, and he has found comfort from his 14 emotional support ducks.  Farm animals, however, are not legal in his Ohio town, and there is a hearing to force Welker to get rid of the ducks!  We at Shrink Rap say NO!  Let the vet keep his support ducks! So long as he does so in a way that does not disturb others or does not endanger the ducks, we're on his side.  And apparently the same town allows one therapy pot-belly pig per family, so why not some ducks?  Link to the article is Here and there is a video of Welker with his ducks.

Finally, over on Clinical Psychiatry News, I responded to a reader's comment that the term "shrink" is odd and offensive.  After eight plus years, I think we're moving on as the Shrink Rappers, though I am sorry it offends someone.  What do you think?  Read:  The Stigma of Being a Shrink.

I'm going to try allowing comments again. I miss everyone's input, but I will be moderating for now.

Stanley Family Foundation gives $650 million for Psychiatric Research

From the New York Times, In Spark for a Stagnant Search, Carl Zimmer and Benedict Carey write:

Late on Monday, the Broad Institute, a biomedical research center, announced a $650 million donation for psychiatric research from the Stanley Family Foundation — one of the largest private gifts ever for scientific research.

It comes at a time when basic research into mental illness is sputtering, and many drug makers have all but abandoned the search for new treatments.

Despite decades of costly research, experts have learned virtually nothing about the causes of psychiatric disorders and have developed no truly novel drug treatments in more than a quarter century.

Broad Institute officials hope that Mr. Stanley’s donation will change that, and they timed their announcement to coincide with the publication of the largest analysis to date on the genetics of schizophrenia.

Let me also encourage you to listen to the podcast linked to this article.

Psychiatric Research Revival, Second Thoughts About Consciousness, Take-Home Sleep Tests 0:00

Play

A family pledges one of the largest private gifts ever for scientific research; why we may never have all the pieces necessary for a theory of everything; sleep apnea tests can now be taken from the comfort of your bed. David Corcoran, Michael Mason and Joshua A. Krisch

 

Does Anti-psychotic Withdrawal Make People Kill?

So here's an interesting article in the Irish Times: Niamh O'Donoghue writes in "Murderer accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court."  I'll let you surf over there if you want to read more, the title says enough for me.

My first thought was :  Really?  People stop their medications all the time, cold turkey, without doctor supervision or approval, and they don't generally kill people.  So how do you know if someone's "symptoms" --like agitation -- are he result of medication withdrawal, or the result of a recurrence of the original illness that the medication was treating?  There's not a great way to sort that one out, but I was befuddled by the idea that one would attribute murder to medication withdrawal.  Maybe that should be on the TV commercials with the list of side effects, "Stopping this medication suddenly can lead you to kill people." 

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at: http://www.independent.ie/irish-news/courts/murder-accused-was-unable-to-refrain-from-killing-the-deceased-because-of-medication-withdrawal-psychiatrist-tells-court-30437572.html#sthash.6SAmLiC6.dpuf

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at: http://www.independent.ie/irish-news/courts/murder-accused-was-unable-to-refrain-from-killing-the-deceased-because-of-medication-withdrawal-psychiatrist-tells-court-30437572.html#sthash.6SAmLiC6.dpuf

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at: http://www.independent.ie/irish-news/courts/murder-accused-was-unable-to-refrain-from-killing-the-deceased-because-of-medication-withdrawal-psychiatrist-tells-court-30437572.html#sthash.6SAmLiC6.dpuf

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at: http://www.independent.ie/irish-news/courts/murder-accused-was-unable-to-refrain-from-killing-the-deceased-because-of-medication-withdrawal-psychiatrist-tells-court-30437572.html#sthash.6SAmLiC6.dpuf

Shrink Notes: what does your doc think of you?

I've written before about shrink notes back in 2011.  See Here and Here.
With the increasing transparency we're seeing with electronic records, there are now systems that allow patients to access their doctor's notes.  The first time one of my patients did this, he casually mentioned that the record included the wrong dose of a medication, and I suggested my patient might want to tell his doctor about this.  

In psychiatry, we've been a bit touchy about this.  Patients might be distressed to see what we write about them, they may see some of the terms we use to describe them (like delusional?) as being negative.  

The New York Times has an article discussing a pilot study in Boston to give patients electronic access to their therapists' notes.  In What the therapist thinks of you, Jan Hoffman writes: 

The pilot project has raised questions in the mental health community. Which patients will benefit and which might be harmed? How will the notes alter a therapeutic relationship built on face-to-face exchanges? What will be the impact on confidentiality and privacy?

And the project presents difficult choices for those who argue for parity between medical and mental health patients. Should patients with schizophrenia, for example, who may stop taking their medication after reading that they are doing well, have the same access to treatment notes as those with irritable bowel syndrome?

But the lingering underlying question is, do patients really want to know what their therapists think? Dr. Kenneth Duckworth, who is the medical director of the National Alliance on Mental Illness, an advocacy group, said: “I’ve offered to share my notes with patients and they’ll say, ‘No, I’m good.’ But it’s a good concept that should be researched.”

The article goes on to describe the content of some therapist's notes and the impact it has on patients to read it:

He clicked open another therapy note.

Mr. Baldwin “is continuing to try to push himself to get out more and to be more socially connected even while his emotions tell him to do the opposite,” Mr. O’Neill wrote, adding that his patient is “clearly making good, and even courageous, efforts on a number of fronts.”

Mr. Baldwin, who celebrated his birthday recently with a museum lecture, movie and dinner, flushed with pride.

Hmm, I thought.  These are the type of interpretations I made aloud to the patients, they aren't the stuff of my notes, and if they were, I'd be living in the office trying to write accurate process notes of sessions.  A lot goes on in a session, and notes of this type could be very long.  I'd be hard pressed to feel I could prove that someone's emotions were telling them not to be socially connected and to stay inside -- what does that even mean?  Oh, truth be told, I write really boring notes.  In 20+ years no patient has ever asked to read their notes, and if they did, they'd find it a really boring read.

I'd love you're input, but comments are still off while the blog settles down. 

  

Guest blogger Dr. Sana Johnson-Quijada on Freedom and Self Care

I met Dr. Sana Johnson-Quijada at the APA Annual Meeting this year in New York.   Sana has her own blog Friend to Yourself, and I invited her to do a guest blog on Shrink Rap.  In honor of Independence Day, she sent the following post. 

Self-Care is Freedom, is Democracy, is Because We Are Accountable

authenticsociety.com

Self-Care Tip #159 – Be accountable for and to yourself.

It was about 100 degrees Fahrenheit, which in my part of the world is considered hot.  But in Washington D.C., I considered that temperature general anesthesia.  I was breathing it in and trying hard to remain alert.  Just when I thought I could hold out no longer, I saw him.  Big and expressive, the long form of Abraham Lincoln was there, surrounded by loud irreverent people.  My brother and I were wiping sweat out of our eyes trying to keep track of our kids.  We wanted to read the Gettysburg Address for our kids, and found ourselves screaming.  The kids could barely hear the words above the disinterested rabble around us.  Despite all this, I was choking; a weepy, sweaty, nearly anesthetized but free American.

Four score and seven years ago our fathers brought forth on this continent a new nation, conceived in liberty, and dedicated to the proposition that all men are created equal.

Now we are engaged in a great civil war, testing whether that nation, or any nation, so conceived and so dedicated, can long endure. We are met on a great battle-field of that war. We have come to dedicate a portion of that field, as a final resting place for those who here gave their lives that that nation might live. It is altogether fitting and proper that we should do this.

Just down the corner from Lincoln is a president’s list of sites to see, informers and reminders of who we are and where we came from.  However, none of them were “my Lincoln” experience.

But, in a larger sense, we can not dedicate, we can not consecrate, we can not hallow this ground. The brave men, living and dead, who struggled here, have consecrated it, far above our poor power to add or detract. The world will little note, nor long remember what we say here, but it can never forget what they did here. It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us—that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion…

A couple of days ago, writing the post about how stress intersects with medicine, I remembered “my Lincoln.”  It may seem like a stretch at first but take a minute.  Self-care is a way of saying, “I am free.”   In places where life is cheap, almost without value, self-care is not much of an option.  It is because of freedom that we can extricate the meddling fingers, the invasions, and be the keeper of our own private spaces however we choose to.  It is because of freedom that we can tell people that although my brain is ill and although I take medication, I am equal. Saying that is self-care.  Saying that is possible if we take that freedom to keep our own accountability for our own selves.  Accountability is not the same as blame.  Having accountability for our freedom is not the same as being at fault for what came before freedom, nor our current conditions.

—that we here highly resolve that these dead shall not have died in vain—that this nation, under God, shall have a new birth of freedom—and that government of the people, by the people, for the people, shall not perish from the earth.

If you’re not accountable to your inner self, if you’re only accountable to your actions, or you’re only accountable to what others determine and define about you, than you are not free.  You are blamed.

Accountability is such a tender privilege.  We might lose it if we forget who we are, where we came from and our rights to freedom.  Democracy is self-care.

Question:  How do you see the relationship between self-care and your freedoms? 

I practice psychiatry and parent, with my husband, our 3 small children.

Woven into this, writing and connection to community continues to bless me.  I am grateful.