Things I Wish I Knew

We come to day with day with a list of Shoulds we take at face value (--where would you like me to begin? Don't smoke, don't drink excessively, don't be overweight, exercise, take your meds, ingest enough calcium, don't shoot heroin, stay out of jail, don't quit too many jobs, get your screening colonoscopy at 50, yearly mammograms after 40, wear a condom, sunlight is good, sunlight is bad, sunscreen is good, sunscreen is bad, coffee is good, coffee is bad....) only to have them rethought time and again. Roy is now finally off his HRT or so I'm told, he still doesn't look post-menopausal to me.

A few things I find myself wishing I knew the answers to:

Will my children be damaged by all the video-game playing I allow?
Will my relationship with my children be damaged if I don't allow them to play video games and survive the inevitable fights it will cause.

If they go out to ride their bikes instead-- nice healthy exercise--will I wish they'd stayed safely home playing video games if they get hit by a truck?

Why didn't my children come with instruction manuals?
--Inspired by yesterday's snow day and my patient today who is consumed with guilt and a sense of perfectionism with regard to her parenting. Something it's easy to distance myself from during a psychotherapy session, but sometimes strikes a bit close to home.

Will some awful consequence of Gardasil (the new HPV vaccine) be discovered 20 years down the line?

If obesity is so fatal, why, since the 1950's are there so many more obese people and why is the average lifespan 10 years longer?

Why do some people seemed to be unscathed by decades of smoking marijuana?

When my patients chronically misbehave and are completely uninterested in changing (for example, young people who enjoy spending their time drinking to excess in bars, others who repeatedly and without regret sleep with strangers, those who consume large doses of prescription narcotics prescribed by someone else, or people who just won't entertain the idea of abstaining from marijuana)-- am I wrong to continue to treat them on their terms?

If I simply refused to treat them unless they get treatment for their addictions, would they a) stop coming, b) stop telling me about their bad behavior, or c) get treatment and clean up their acts?

When a patient complains of intolerable feelings of agitation or other vaguely defined distress, and gives me the "walk a mile in my shoes" talk, is it wrong that I sometimes offer a prn very low dose of an second generation anti-psychotic, along with the warnings about possible induction of diabetes and dyslipidemia, and let them make the decision about whether to take it? Is it funny that I never ask myself if I should offer that script for very low dose prn Xanax which is what they really want?

And what about the patient whose last depressive episode (of many) lasted nearly a year and who has never been able to tolerate lowering her zyprexa, should I stop it given that her risk factors for diabetes and heart disease are screaming in my face (they preceded the zyprexa, but it can't be helping)? How do we know the worst of two evils?

Were those 250 extra children who died of suicide in 2003 compared to 2004 (see Pediatrics, annual vital statistics, death figures on page 13), children who were not taken for mental health care, or not offered anti-depressants because of the Black Box Warning added to anti-depressants by the FDA?

Sometimes I wish I had a crystal ball that worked, one where I could fine tune it to ask the subtle what-ifs. When it comes to the long-term prognosis for diet Coke and hair chemical abusers, well, there are some things I just don't want to know.

P4P

Dr Rob over at Musings of a Distractible Mind blogs about the next big thing in sticking it to patients and providers in the name of shareholder profits: Pay For Performance. He explains the new acronyms, plus a few more (I like P4Poop).

He really nailed Psychiatry.

Bridging the gap between research and change in practice

The Journal of the American Medical Association (JAMA) and the Institute for Healthcare Improvement (IHI) have initiated a collaboration, funded by a grant from the Robert Wood Johnson Foundation, that will make it easy for health care professionals to review and discuss research findings from recent JAMA articles with the author. The participants of this Author in the Room program will be surveyed later to determine the degree to which they have implemented appropriate chnages in their practice. Participation is free and is by conference call (you have to register). The March 21 program will be on "Development and Validation of Improved Algorithms for the Assessment of Global Cardiovascular Risk in Women: The Reynolds Risk Score."

This is different sort of program than just your average CME event. The goal is to learn something that can be applied today in your practice to improve the health of your patients.

I hope we start to see more of this type of collaboration and effort to translate research findings into current patient practice. I also hope that this process isn't hijacked by Big Pharma into another marketing avenue (though it would seem hard to prevent).

If I see that JAMA is doing one of these programs for a psychiatric illness, I will let you all know.

Can't We All Speak English?

To The Maryland General Assembly: Can’t We All Speak English?



I was so pleased to see House Bill 885: English Language- Formal Recognition. At last, I thought, a bill that would require our state legislators to write statutes in something that resembled plain, easily comprehensible English. I was disappointed to read the synopsis of HB885: “Designating the English language as the official language of the State of Maryland ; and making provisions of the Act severable.” The proposed bill has nothing to do with the creation of laws that we can all understand. The purpose of House Bill 885, from the best I can figure, is to assert what already obviously is.

For the past three years, I have been a Bill Screener for our local shrinkiatric organization. This means that every day during the legislative session, I read a portion of the proposed legislation—specifically any bills ending in the numbers 81 to 90-- and I flag those that might pertain to the practice of psychiatry or might have an impact on the care of psychiatric patients.

Reading proposed legislation can be a challenge. Take, for example, Senate Bill 687 Youth Services Bill—Services. The synopsis reads: “Repealing a provision that makes the provision of specified required services by a youth services bureau subject to the availability of funding; etc.” And that means? Okay, if I think about it long enough, and if I wait a few days for the First Reading of the bill to be available on-line, I might get it, but I’m left to ask why this has to be so complicated.

As a committee, when we look at proposed legislation we try to figure out what exactly the language means. Legislation is written in grammatically incorrect, wordy, obscure, and nonspecific terminology that defies understanding by anyone not used to reading it, and perhaps even by those who are used to reading it. We are left to ask, what is the intent of the bill and what might the unintended consequences of its passage be?

I wonder why legislation isn’t written in short sentences with obvious intent. If you’re not sure what I’m talking about, I invite you to look up Senate Bill 821: “Prohibiting a person from tethering or confining a pregnant pig for a specified amount of time in a specified manner; providing exceptions to the prohibition; establishing specified penalties for a violation of the Act; and establishing that each instance of tethering or confining a pig constitutes a separate offense.” This 3-page bill declares that it will be illegal to tether pregnant pigs except, of course, for specified reasons. “Pig,” “farm,” and “turning around freely,” are defined, but oddly, “majority of any day” is not defined and there is nothing to indicate how a farmer might be expected to know his pig is pregnant. I’ll readily admit that I didn’t look up the 1999 Annotated Code this will serve to supplement. Can I wonder whose agenda this is, why just pigs, and why just pregnant pigs? Granted, a subject I know nothing about, but it seems there could be a law against restraining pregnant pigs that the average psychiatrist could understand with a single reading. It took me three readings, slowly, and the language, which tries so hard to be precise, remains vague and leaves plenty of room for pig-restraining violators to wiggle free.

Apparently, I’m not the first person to complain about “legalese.” The Plain Language Association International has members in ten countries and The Plain English campaign has existed in London since 1979. Most discussions of the use of plain English, however, refer to legal contracts, only a few to the language of proposed legislation. Shouldn’t our laws be written with language that includes, rather than excludes, the citizens of Maryland? Simply put, any member of the Maryland General Assembly who proposes a law requiring that our statutes be constructed in simple sentences will get my vote.

Heads, You Lose

During our last podcast taping Dinah was busy sending email to Roy and Roy was distracted by cookie dough. It's amazing we ever get any of these things done. Anyway, I promised to do a followup blog post on the issue of neurological injuries and criminal culpability in response to Sandra of OmniBrain's question. Here it is.

First of all, in order to be guilty of a crime the state has to prove two things: that you committed the criminal act (also called the actus reus) and that you had a criminal intent or mental state (the mens rea). Both of these elements must be proven beyond a reasonable doubt in order to convict someone of a crime.

Mental state issues come into play when the defendant puts up what's called a 'mens rea' defense---for example, an insanity plea. Another type of mens rea defense is generically called a 'diminished capacity' defense. This just means that there was something about the defendant's thinking that impaired his ability to form a guilty intent, but this 'something' is not so severe as to be considered insanity.

The most common example of a diminished capacity defense is acute substance intoxication. By law this is barred as an insanity defense, but it can reduce mental state culpability to a more serious crime. For example, someone charged with first degree murder could be acquitted of that charge because of intoxication and instead convicted of the less serious offense of manslaughter. Diminished capacity defenses don't generally lead to acquittal, just conviction on a lesser charge. Some states bar the use of diminished capacity completely.

I don't have exact numbers but off the top of my head I can tell you that easily two-thirds of the prisoners I see have a history of some type of head trauma. They do impulsive things and get into accidents. They wreck their motorcycles and their cars. They get into fights and get the...uh...stuffing beat out of them. Outside of the trauma area they also carry the neurologic sequellae of their lifestyles---alcoholic dementia, HIV dementia, sometimes strokes from untreated hypertension. All this is added onto environmental developmental insults like lead poisoning.

OK, so how does brain injury or neurogic impairment relate to criminal prosecution?

My answer is that there's not much of a relationship, although if the injury is severe enough it could fall into the realm of insanity. The fact of the matter is that there's a big leap between what you see on an MRI or on neuropsych testing and a person's actual functional capacity. The more prisoners I see the more I realize you really don't need to have that many functional neurons to get by in life. When it comes to moral reasoning, you need even less. Child development theorists know that social conscience is usually in place by the age of ten. A basic understanding of Miranda rights can be grasped by anyone with a fifth grade reading level. If there's any real question about it the judge can order a competency assessment to determine mental capacity to stand trial.

This is probably more than anyone needed or wanted to know, but here you have it.

Pass the cookie dough.

My Three Shrinks 13: Lost It In Space

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So, we kinda have a space theme going today. This is consistent with my long-term wish to be a space-doctor (no wise-cracks, please). I figure those folks stuck on the eventual moon base (or on Mars!) could use a psychiatrist, don't you think? There's also a cameo appearance on this podcast of Dinah's daughter. Enjoy.

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March 4, 2007:


Topics include:

• How does NASA handle psychiatric emergencies in space? The recent 'astronaut goes wild' headlines get us talking about NASA's procedures for handling acute psychotic breaks and suicidal behavior in space. Also, go to page 847 of the above-linked document to see the list of medications which are kept on the ISS (International Space Station). Listen to the podcast to find out which antidepressant is the SSRI of choice for NASA.
  
• Q&A: Sandra, a prolific, Canadian Barbie Doll (it's true, look at her picture) from Omni Brain and NeuroFuture sent in a multi-part question: "Do you agree that neurological factors may diminish legal responsibility (but not excuse it) in ways not currently considered by the legal system, i.e., that don't fall in line with the McNaughton insanity defence, and the legal system should change in accordance? In what ways, based on what you see in the population you treat? Also, in cases like compulsive sexual offenders, do you support chemical castration and similar means of crime prevention?" This is obviously a Clinkshrink question, but we have a spirited discussion about these areas.

Next week: Visitor survey; Top 25 crimes of the last century; What do psychiatrists do to prepare for the next session (thanks, DrivingMissMolly); NHS fiasco.
Send us your questions at mythreeshrinksATgmailDOTcom.
Last week's musical snippet was from Suzanne Vega's 1987 release of Language from the album, Solitude Standing. (Also, you've gotta check out this Tom's Diner-inspired I Dream of Jeannie video.)

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Find show notes with links at: http://mythreeshrinks.com. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening.

Neurophilosophy lists psyc blogs

Here is a compilation of great psychiatry and neuroscience blogs that I wanted to share with you. Happy browsing.

Small Town Shrink with Insights From Guest Blogger Mellowdee

I'm city folk, all the way. I've never lived in a small town much less anywhere rural. And while Baltimore sometimes feels oddly provincial, we have lots of docs. Lots. With Johns Hopkins, the University of Maryland, and Sheppard Pratt as the forces in academic psychiatry, there are also many community hospitals which offer inpatient and emergency psychiatric care, plenty of psychiatrists in private practice, and I'm fond of saying that in my neighborhood there are more psychiatrists than cockroaches. How many shrinks can fit in one community pool at a time? Oh, a bunch.

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I've always thought it would be hard to work as a psychiatrist in a small town where everyone knows everyone. If there's only one psychiatrist, doesn't that mean that he probably treats some of the other docs, some of the people he may run into socially? And what if the only psychiatrist, or his family member, has a mental illness: where does he go for treatment? And what if he needs psychotherapy-- who does he talk to? And what about professional consultation on difficult patients, a friend to blow things by (see my post on Camel), or finally, how does he get together to do podcasts for his blog?

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So when I put up my post on the 10 things I don't like about being a shrink, there came a reply from Mellowdee, a small town psychiatrist. I liked her response so much, I wanted to put it up as a guest post. And here you have it, insights from a small town shrink:

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mellowdee said...
I, too am blogging when I should be working! In addition
to all the biggies, like getting shafted by insurance companies, what I find
annoying about being a shrink relates directly to the fact that I live in a tiny
town. There are only four other psychiatrists in private practice, and one of
them is my husband. There is a small local hospital which I would never in a million years use if a patient needed admission, the care is so abominable.

1. Lack of referral resources means I'm taking care of super sick people that should be referred to a more intensive setting, but there is no such place to send them. There are many patients in the practice that aren't going to get better as a result, when they might if the resources were available. It's extremely frustrating.

2. Firing patients for not paying, and then seeing them at the post office, the movies, a restaurant, at my kid's school, etc. and having them come over, to tell me how much they need my services (without mentioning the outstanding balance), while everyone around is listening with ears flapping. It would be a challenge for Emily Post.

3. Having local idiot GPs change my patient's psych meds. Either because a. the patient calls/sees him/her for psych symptoms instead of me (while extremely annoying and grounds for firing the patient, the patient is still the patient and can't be expected to be reasonable), or b. the GP is an arrogant idiot who has boundary problems and changes psych meds during an annual checkup or whatever. When the patient crumps, guess who has to deal with it?

4. Prescribing off label doses (standard practice since I get the sickest of the sick) of the one medicine the patient
has responded to, which, even though I take the time to fill out the proper
paperwork, the insurance refuses to pay for.

5. Being a doctor, even if only a shrink, in a small town makes me a celeb, and all my behaviors (my husband's and my kid's) are observed with great interest. It's taken me years to stop worrying about it, and simply to live. Early on, I had a patient tell me that the state of my husband's car was a disgrace (he's a slob, it was undoubtedly littered with take out bags, empty cardboard coffee containers, dirty snotrags, drifts of articles, sneakers and exercise equipment...). I had to laugh! I shrugged,and commented that when you're married, you have to pick your battles.(The patient didn't agree with me.).

6. Getting stuck with a patient that should be a clinic patient (i.e. doesn't pay reliably, is very needy, has constant drama in his/her life, calls and pages a lot) but the clinic is so overwhelmed it would take six months to get the patient there, and the patient isn't behaving in a way that's obvious enough to justify refusing to continue seeing them....

Sigh. I have to stop. There's more, but why go on?
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As you may have guessed, I won't be moving to South Dakota anytime soon.

Funny Running Into You Here

I'm coming up for air and a quick blog post. For the last couple weeks I've been codestorming, lost in a flurry of flow-control statements, if-then and for loops, switch blocks, dropped semicolons and variant datatypes (cursed be he who invented the variant datatype for to such belongs the world of sloppy programming). After 18 months waiting for the bureacracy to give me a regional information system I can use I finally gave up and built one myself. It took two weeks. Meanwhile no one in my department has ever been able to use the system we're supposed to be using. It's enough to make a taxpayer cry. Anyway, my personal system is pretty much done except for minor cosmetic tweaking.

But that's not what I was going to blog about.

Today I wanted to talk about what happens when you run into your patients outside of professional hours. In my case, it can be interesting.

I went to the post office to mail off my taxes and I noticed someone standing toward the front of the line who looked awfully familiar. Thanks to my recent accident I've been meeting a lot of car salesmen lately, so I was thinking it was maybe some business person or a public defender type. Then it hit me---a former inmate. He either didn't recognize me or was reluctant to acknowledge me, which was understandable. In a public place you just don't strike up conversations about your former incarceration, much less about your mental health care even if you haven't been locked up.

Generally meetings with former inmates are fine if I run into them on the street. Usually they recognize me first since I get thrown once you take someone out of a prison uniform and put them in street clothes. I usually hear about how things are going "on the outside", whether or not they've been able to get mental health care, how long they've stayed clean and how much time they have left on parole. They seem happy to see me and I like hearing about how they're doing. Even when they're not doing so well they seem happy to see me. The most awkward meeting was coming across a former patient a the time of arrest, handcuffed and prone on the street in front of my parked car. "Hey doc! I'm going to need your help!" he said. I reassured him I'd be there when he got to the institution and reminded him how to get in touch. He said he would.

Overall I'm grateful I only work in men's facilities. It kind of spares me from thinking about running into former patients in the locker room at the gym.

My Three Shrinks Podcast 12: Bilingual

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We had two other topics recorded from a prior session, one on the side effects of psychotherapy and the other on the street value of psych drugs in Las Vegas, but GarageBand somehow lost them (I really don't think it was me.) If I find them later I'll put them out in a podcast.

As a result, this one's shorter... about 18 minutes.

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February 25, 2007:

Topics include:

• Evolutionary Psychopathology. LA Times article, The Mind as it Evolves, by Julia M. Klein, about a developing area that theorizes that the illness of depression developed as an evolutionary strategy, which helped signal and stabilize social ranking. Very interesting reading. See also the journal article, The evolutionary significance of depressive symptoms, by Matthew Keller and Randolph Nesse from VCU.
  
• Mental Health Parity Act of 2007. Well, we have been trying to get this passed for years (see NAMI's review), despite popular bipartisan support. It passed the Senate, and will hopefully pass the House for the president's signature. We also talk about Maryland's 1993 landmark parity legislation.
  
• Psych Blog: Psychiatry for All, by Saminkie. A psychiatry resident in Baghdad who writes about learning psychiatry while having to deal with bullets, explosions, no electricity and other war-related problems. (Sent to us by DrivingMissMolly.)
  
• The Psychiatrist Blog, by Michelle Tempest. A UK psychiatrist, and author of The Future of the NHS, blogs about psychiatry, health and politics.
  

Next week: Could be anything. Send us your questions at mythreeshrinksATgmailDOTcom.

Last week's musical snippet was from Monty Python -- Spam; and Finland, Finland, Finland.

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Find show notes with links at: http://mythreeshrinks.com. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

I'm Not Old

I was eating lunch with a friend the other day. She was talking about her sick friend, her husband's upcoming big birthday, her mid-life crisis of sorts.

"I'm not looking forward to this next phase of life," she said.

"Huh?"
"Getting older. What's to come."

Age, I've decided after years of watching people, is a matter mostly of luck and partly of mindset. Mostly of luck. I've seen people who are old by 40. I've seen people in their 70's, and sometimes even 80's, who are still full of life. I recently treated a man in his early 90's who still had stuff going on.

"I'm not getting old," I said. I feel fine, why would I spend my time thinking about impending disability.

My friend is a runner, she's tall, slim, beautiful, and has two sons in elementary school. She looked at me shocked.

"You're my age. You're in denial."

Perhaps I am. My children, especially the younger one, tell me I'm old at every turn. Actually, I'm a bit younger than most of their friends' parents. I tell them so, it bounces off and lands with a thud.

Back in the day, I think. I can remember, and I'll leave you with a list:

Going to the library to do research out of books.

Finding those books after looking them up in the big card catalogue which took up half the room.

Finding journal references in The Readers' Guide To Periodic Literature (or something like that) and reading the reels on microfilm.

Answering the phone, attached to the wall.

Not knowing who was calling until you actually answered.

Dialing. Really, dialing.

Staying home to wait for a call.

Using pay phones, routinely.

I was in med school the first time I saw a cell phone. It looked like a vacuum cleaner. Well, not really.

Television in black and white, though the neighbors had color.

Getting up to change the channel.

TV Kids who said "Golly Gee" and no one cursed.

Saying to my big brother: "I turned it on, you turn it off," when no one wanted to get up.

Saying to my big brother: "You turned it on, you turn it off," when no one wanted to get up.

Television shows that had to be watched when they aired, not on video tapes or TiVo.

Movies on big screens only, as double features.

Radio: shaped like an orange ball that played AM only. Taking it to the beach.

Records that came as 45's and 33's and got scratches.

Oddly enough, all the recording artists were the same then as now.

Riding in cars without buckling the seat belts. (I don't remember ever being in a car that actually didn't have seat belts).

Cars where you stuck the key into the lock to open the door.

Cars with roll down windows.

Typewriters. I remember typewriters. I even remember manual Smith Coronas. I remember carbon paper and erasable paper. (Oh my God, I AM old.)

Keypunch and all those keypunch cards. I remember COBAL.

Huge computers that filled cold rooms. Something called DEC-10.

Volkswriter, and then WordPerfect.

Elavil and haldol and there was no Prozac, no atypical anti-psychotics.

Patients stayed in psychiatric units for weeks to months, and even years.

I remember psychiatric units with Adirondack chairs on the lawns and patients went home on overnight passes.

Psychiatric residents who routinely had personal analyses (this may have been a New York thing).

I remember classrooms filled with wild little boys who didn't take stimulants.

I remember a time when I'd never met a child with autism. Learning about autism in college, a very rare condition.

I remember Tab and the world before Diet Coke. Cheerios were unflavored and the only bread was white bread. Scooter pies, Pop tarts and plastic Twinkies tasted good, but Cap'n Crunch ruled. Ronald McDonald toured and lines ran around the block.

So maybe I am old. Someone, please hand me my cane.

Home Work

This is for our obstetrician blogger friend who wanted some help with her homework: preparing a lecture for OB/GYN residents on psychiatric issues in pregnant women.

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I'm going to ramble (I'm good at that), no references, no specifics.

What do we do about psychiatric disorders in pregnant women? This is a tough question, mainly because we know so very little, it's not unlike the issues that get put forth regarding the efficacy and safety of treatments in children: both are populations that don't get experimented on. To figure out the teratogenic effects of medications (one option in treatment) on the unborn fetus, studies are done on pregnant laboratory animals, which often tell us little about the effects on unborn people. We simply can't design studies that purposefully expose pregnant women to medications and ask Hey What Happens to those kids. What we know is incidental: someone taking the medication gets pregnant, it's reported, outcomes are followed up on. Little is known about exposure at varioius times during fetal development, and outcome is generally limited to structural birth defects and behavior in the immediate post-natal period. So there's nothing that says that a 6 week old fetus exposed to psychotropic drug X is more likely to have reading delays at age 7 or coordination problems or is less likely to fill-in-the-blank. And just to make the story more complicated, we also don't know what effects untreated maternal mental illness have on the fetus, so even if there is some risk from medications, it's looking like very sick mothers aren't good for babies, and maybe the risk of treatment with medication may be better than the risk of not medicating, but this remains speculation as these issues are only just beginning to get the attention they deserve.

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Any way you dice it, I think an obstetrician needs to refer a mentally ill pregnant patient.

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

From my shrinky perspective, I believe the fetus should be exposed to a minimum number of Unnecessary medications, I think they are all Potential toxins. I tell pregnant patients that the threshold for medication is raised: I ask them to tolerate some distress for the sake of the baby, we do this anyway. We ask pregnant women to give up all the essentials: cigarettes, alcohol, otc medications, Diet Coke, street drugs, Diet Coke, coffee, hair chemicals. Perhaps we ask pregnant patients to tolerate symptoms of mild depression or anxiety or sleeplessness that we might otherwise offer medication for. The threshold for psychotherapy should also be lowered: talking is unlikely to harm the fetus, frequent sessions provide an outlet for the patient and a means to increase coping mechanisms, and systems are set in place for the therapist to do on-going evaluation and monitoring. Other support systems need to be shored up: family members often must be called upon and all available resources may be needed. A therapist may need to work with the patient on the importance of taking care of herself and accepting help from others: often a difficult thing for moms to do.

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Sometimes, issues related to coping and expected discomfort can be confused with symptoms of mental illness. A woman is sad, tired, nauseated (for Fat Doctor), not eating well, crying. Does she tell her obstetrician that she and her husband are fighting non-stop, that her co-workers are angry about her pregnancy, that the other 5 kids are overwhelming, or does she simply say "I'm depressed," a self-made diagnosis that may or may not be right and may or may not need medications?

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Sometimes, there is no escaping medication: a pregnant woman is so symptomatic that medication must be given. We don't leave patients psychotic (hallucinating or delusional) or manic, or terribly depressed; in these instances we offer medication and do our best to work with what we hope will be safe and we avoid those meds we know are not. I'll leave the lists to you, but the patient gets the best care when the psychiatrist and the obstetrician work together.

So why do I think you should refer? I'll give it to you as bullet points:

• OBs don't spend the time with patients needed to make an accurate psychiatric diagnosis and this is essential.
• OBs don't generally have a good enough handle on diagnosis and treatment of psychiatric disorders to be doing it. (And I don't catch babies).
• If the baby has a bad outcome for any reason, a defense attorney will have no problem targeting an OB who treated a psychiatric illness in an expecting mother.
• If the mother does something horrible because of untreated or wrongly-treated mental illness, this can be catastrophic.
• OB's typically stop seeing the patient 6 weeks after delivery and the patient will need on-going psychiatric care.

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When do you refer?

• If the patient appears to be having psychiatric symptoms that are endangering herself or the baby: a sad mom who isn't gaining the necessary weight due to poor appetite, one example.
• If the patient mentions suicide or harming the baby or any pre-existing children.
• If the patient says she thinks she has a psychiatric disorder or names an illness.
• If you even wonder if you should refer. Phrase it as an evaluation: I'd like you to see a psychiatrist one time just to get a handle on whether there is even a problem.

To our OB friend, I hope this helps.

Nine Months And Counting....And Counting...

I started this post as an email to Midwife With A Knife to help her with her talk about perinatal psychiatric issues. It got long enough that I decided to turn it into a blog post instead. I see Dinah is also working on her part of MWAK's homework and it's a good one. Here goes.

Last November I went to an excellent CME lecture on perinatal OCD. I thought this would be a nice change from the usual maternity-associated illnesses like post-partum depression and psychosis.

First of all, obessive-compulsive disorder is an anxiety disorder characterized by obsessions or compulsions that are time consuming or interfere with social or occupational functioning.

Obessions are anxiety-producing thoughts, impulses or images that are excessive and beyond the range of normal worry about real-life problems. Sufferers usually recognize that they are irrational, and often try to ignore or suppress them. The most common types of obsessions are contamination obsessions followed by obsessions about aggression or the need for exactness.

Compulsions are urges to perform repetitive behaviors or mental acts. They usually happen in response to obsessions and are aimed at reducing distress or preventing some unpleasant event. The most common types of compulsions are checking rituals followed by cleaning or washing. There can also be mental compulsions (repeating words or numbers, counting or reciting prayers.)

The prevalence of OCD is about 1 in 50 people (2.3% of adults). The gender ratio is 1:1 male/female. The prevalence of perinatal OCD is 0.2 to 3.7%. Eighteen percent of new cases occur during the postpartum and 6% during pregnancy. Most women with pre-existing OCD have no change in symptoms with pregnancy, but one-third may have worsening or a change in symptom presentation.

The types of obsessions in perinatal OCD are different than in non-postpartum OCD. Postpartum obsessions are more likely to involve contamination fears or fears of violence (eg. intrusive thoughts to poke the baby's "soft spot", putting the baby in the microwave) than non-postpartum OCD. Patterns of compulsions are also different---postpartum OCD is more likely to involve checking, washing and cleaning rituals. Some OCD patients have been known to call their daycare multiple times a day to neutralize their obsessions.

About half of women with post-partum depression have co-existing OCD, but the OCD is less likely to be diagnosed because of patient concealment and embarrassment. And yes, fathers can get it too.

Treatment usually involves cognitive-behavioral therapy sometimes combined with medication. For the Ob-Gyn crowd, this would be the time to refer. Dinah is writing a good post about meds in the peripartum, so I'll leave that to her.

Hope this helps.

Why Docs Don't Like Xanax (some of us)

[BTW, you might also be interested in checking out our related podcast, #19: Xanax Blues.]

This is in response to JW's question below about the "rules" docs use about prescribing Xanax/alprazolam. Not all docs feel this way, but here's how I think about it. Of course, I am not suggesting that, if you are taking this anti-anxiety drug, you should stop it. I'M NOT. Talk to your doctor if you have concerns.

The half-life for Xanax is short... on the order of 6-20 hours. Halcion is the only similar sedative that has a shorter half-life (and that one has even more problems). Thus, it doesn't stick around long. It is also quite lipophilic, meaning that it quickly gets into the brain. So, it has a quick on, quick off way of working. Sounds great, right?

The quicker a drug works, especially one which makes you feel good in some way, the more addicting it is, as the cause (taking it) and effect (feeling it) are close in time, making it very reinforcing. This is fine if you just take it on those rare anxious moments where you need something to get through it. However, since it works so quickly, many folks start taking it more and more often, until it gets to the point that they are taking it daily. Then they start taking it as soon as they feel it wear off. Before you know it, you are taking it 3-4 times per day. Now, that's not the big problem.

The big problem is all because of your brain's laziness. See, your brain makes it's own natural Xanax-like substance, called GABA. GABA works by inhibiting the brain's natural tendency to speed up. It's like a brake pedal, where the accelerator is stuck in the pedal-to-the-metal mode. GABA keeps your brain from over-working. Xanax (and other sedatives, and alcohol) works by acting like GABA in the brain (sort of). If you start taking it daily, your brain starts thinking "I guess I don't need to make so much GABA because this Xanax stuff is here, so I'll only make 20% of what I usually make." It takes a week or more for your brain to stop making the GABA (which is why just a few days on Xanax won't lead to much trouble), and a week or more for it to start making it again when you stop taking the Xanax.

Here's where the trouble begins. If Xanax wears off in just a few hours, but it takes a week for your brain's natural Xanax to kick back in, what happens in the interim? Withdrawal. What does that feel like? It feels like a panic attack, but worse. High blood pressure, rapid heart beat, tremors, confusion, delirium, hallucinations, seizures. What do folks do when they feel a panic attack coming on? Take another Xanax.

As a hospital-based physician, I see lots of folks, often older, who wind up with severe withdrawal problems from Xanax. It's usually because they run out of the drug, decide to cut back or stop taking it, or something else happens (eg, stroke, get sick) and they forget to take it. Or they don't tell their surgeon they are on it, and 2 days after their hip surgery I get called because they are hallucinating.

Some prescribers think it is a good antidepressant (it's not). Or that, because of the short half-life, it's not as addictive (it is).

So, here are my rules of thumb about Xanax:

1. Avoid it.
2. Keep the doses small.
3. Do not use in older folks or forgetful folks (more likely to forget it, thus more likely to have problems).
4. Do not use in anyone with a history of alcoholism or addiction (yes, that means you have to ask).
   
5. Tell folks to avoid from daily use.
6. If they are on it, warn them that stopping it suddenly, even for a day or two, can result in confusion, hallucinations, seizures, and even death.
   

The Top 10 Things I Don't Like About Being A Shrink

I'm doing this alone-- my co-bloggers are welcome to post their own-- because finding and then nagging Roy is a full-time job. Still waiting for the carpenter to come put things back after we dragged him out to say why he loves his job.

I love my job, as mentioned below in Who Wants To Be A Psychiatrist. But every thing, every job, every relationship, every new or old endeavor, has it's down side, and so this is to present a more balanced side of what I generally think of as my blessed life.

The Top Ten Things I don't like about being a Shrink:

10. Filling out HCFA forms for Medicare over and over and never knowing why they're rejected.

9. Chronic benzodiazepines. The ones that fell down the sink. Why don't zoloft prescriptions ever run out early?

8. The heating unit in my office is awful. It's loud and the room is always too hot or too cold -- this has persisted after it was replaced with a new and improved unit.

7. Arguing with ClinkShrink about who deserves care and what an illness is.

6. No place to lock my belongings in the clinic where I work so I carry my purse everywhere.

5. Wondering if I'll live through eight psychotherapy sessions in a row when I've forgotten to schedule myself a lunch. Or worse, remembering to schedule a lunch, then only having one patient after that, and the patient right before lunch cancels, leaving me two hours of dead space before the last session.

4. Nonsensical paperwork in the clinic.


3. The work of seeing patients who don't talk spontaneously and look to me to guide the entire session, then answer any questions I can think of in single sentences. These can be long sessions.
2. The chaos of patients who simply don't show up or who repeatedly cancel at the last minute. Especially if the reason is that it's the only time they could get an appointment with their hairdresser.

And the Number One thing I don't like about being a psychiatrist.....

1. Talking about unpaid bills, which I have on ocassion let go much longer than I should.