I Don't Talk Too Much

OK, for the record, DINAH TALKS MORE THAN I DO. Really. Ask her husband. Ask the kids. Ask the judge. Ask Max. Heck, Max talks more than I do. (But at least I don't back up to total strangers and expect to get my butt scratched. Max, you are a strange dog.) I happen to know that a lot of listeners have trouble telling our voices apart. Here's a rule of thumb: if you hear talking, it's Dinah.

Here are some cues that may be helpful:

Dinah is talking if you hear references to:

• complaints about insurance (I don't take insurance)
• discussions of television plots or episodes
  
• prescribing Seroquel for hairy tongues
• the Boston Red Sox
• lost cell phones

Clink is talking if you hear:

• a Canadian-like accent, eh?
• a bad pun or two (or good puns, depending on how you look at it)
• any references to obscure/boring legal cases, infamous crimes, human sacrifice or cannibalism. Well OK, anything really really weird.
• geek humor, hex codes, computers, programming or Apple computers (now is the time for Zoe Brain to leap to my defense. We lady geeks need to stick together.)
  

OK, that being said on podcast #28 you will hear me talking the most. Finally. That's because all my three topics coincidentally got put off taping until the second one (we do two at once). Here's hoping this will help with any confusion.

My Three Shrinks Podcast 27: Shrinks On The Take

[26] . . . [27] . . . [28] . . . [All]

---

Back in Dinah's back yard today. For our U.S. readers, please have a safe July 4.
And if you live in France, the UK, Canada, Cuba, or Guantanamo Bay, Dinah wants your comments on her post about Michael Moore's Sicko. Okay, okay, citizens of other countries are welcome to comment, too!

---

July 1, 2007: #27 Shrinks On The Take


Topics include:

• Doctor Anonymous has new Podcast, where he talks about chatty doctors, nursing home patients, and discovers BlogTalk Radio (similar to TalkShoe).
  
  
• Vermont Shrinks Rolling in Pharma Dough. The New York Times reported on doctors who get money from drug companies, finding that in Vermont the #1 specialty to cash in is Psychiatry. Vermont has a law requiring the reporting of such income, and the story misleading suggests that the average Vermont psychiatrist gets $45,000 from drug companies. Closer reading shows that there were 11 psychiatrists who received an average of $45,000. Still. What are they getting paid for? Here's some insight from a #2 specialty: Endocrinologists. A US Senator has suggested that all such income get reported, just like they have to do (makes sense to me).
  
  
• Zyprexa Class Action Lawsuit for Fraudulent Marketing Zips Ahead. CL Psych informs us that a judge is allowing this suit to go forwards, based on allegations that Lilly engaged in fraudulent marketing of Zyprexa for unapproved uses. See also the March FDA Drugs for an FDA warning against Provigil. We launch into a wider discussion about off-label prescribing and combination medications. Listen to find out the #1 prescribed drug which is FDA-approved for bipolar depression (hint: it's not an SSRI).
  
  
• Doctors Who Talk Too Much. The Archives of Internal Medicine has an article by McDaniel et al., which has been in the news. They sent fake patients into participating physician offices over the course of a year and recorded the interactions, categorizing the utterances in various ways. One-third of the visits contained physician "self-disclosures" (talking about themselves), with 85% of these not being useful. It doesn't seem that they asked the pretend patients how useful these discussions were. I view the study's conclusions with suspicion. I would like to see compliance rates and outcome measures compared between a group of patients whose physicians self-disclose and one whose physicians do not (ideally, assignment would be randomized, and a physician would have patients in both groups).
  
  
• Q&A: Can you have a mental disorder and still become a mental health professional? Listen in as we address this question from a listener.
  

The song at the end is called "Talk Talk," by the group, Talk Talk. You can get it at iTunes.

---

Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

I Saw Sicko

In the comment section to Roy's Mental iPhone post, Rach asked if we've seen Michael Moore's Sicko.

It wasn't on this weekend's agenda, but hey...Okay, so I couldn't resist (-- someone actually wants my opinion!!), and for Rach, I spent Sunday evening watching Sicko. My husband left the Red Sox with a tie score for this.

Okay, so Sicko. Michael Moore starts with the statement that he thought health insurance companies want to help people, and he's had this unnerving revelation that they want to make money. He has no trouble finding examples of people who've been denied coverage for the lamest of reasons (too fat, too thin, too too), or those who've been denied at the mercy of mis-managed care. He finds ex-industry employees riddled with guilt who pour tears. He villainizes everyone from John F. Kennedy, Jr. to Hillary Clinton (yup) to George Pataki. He finds people who've been dumped in the street by hospitals, delirious and still in hospital gowns, as well as Ground Zero heroes with no access to health care. It's one heart-wrenching sob story after another.

Where's it any better? What's the answer? Socialized medicine. It's better in Canada, England, Cuba, and even Guantanamo Bay, where the ratio of prisoners to health care workers is 1:4 and state-of-the-art-care is readily available. France doesn't just have great free health care where doctors make house calls in cute little vehicles, but workers get 100% disability pay, weeks and weeks of vacation, months and months of maternity leave, and the government sends out free nannies to do your laundry and cook dinner. Why would anyone live here if they could live there? And don't worry about physician reimbursements with national health insurance: the French doctor drives an Audi and lives in a million dollar home.

So what did I think? Gosh, it was nice of Rach to ask!

I guess I thought the story was one-sided. It sounded like no one in the US, even the well-insured, is happy and everyone is screwed by the health insurance companies who are digging into every last health record to deny the last surgical claim because the insured didn't reveal that once upon a time they'd had a yeast infection. It's not hard to find unbelievable health care stories, and Mr. Moore didn't seem to have any trouble trumping them up. I've heard them too (none involving dead children), but I've also heard people say their illnesses were completely covered without any battles, and that part of the story was not mentioned.

Sicko was engrossing, entertaining even, thought-provoking, rage-provoking, and there were several laugh-out-loud moments. Michael Moore is nothing if not clever. Is socialized medicine the answer? To read Dr. Crippen's NHS Blog or Shiny Happy Person's rendition of life working in the NHS, there's another story to be told. My opinion would be a random one. I've no experience in this arena, and I'd love to hear from our readers in Canada, Great Britain, France, Cuba, and Guantanamo Bay.

We all know the system's broken. I hope Michael Moore's sensationalized presentation will help to change things.
For the record, Psychiatry was totally ignored in Sicko. One Ground Zero hero had PTSD, but this was presented as a dental problem (he ground his teeth). Maybe in Mr. Moore's next movie?

"Going Mental" for iPhone

Leander Kahney, the managing editor of Wired magazine, was quoted as saying, "They are going to go mental for it." He also predicted iPhone-inspired muggings and selling of first-borns. Folks have been waiting in lines all week just to get first dibs on Apple's new digital wunderkind. It is only a matter of time before i see an iPhone-inspired psychiatric problem in my E.R. And i know just the type of medication to use: an SSRi (or, iSSR?).

John Paczkowski from Digital Daily has dubbed the iPhone obsession iOCD -- and apparently this diagnosis is now in the DSM! Funny... the AMA stopped short of calling video game addiction a disorder, but there is clearly an overboard quality to the iPhone hype. Google "iPhone" and you get 118 million hits this evening, which is 50% more than yesterday. This is more than Paris Hilton and Britney Spears combined. And, it is certainly a few million more than "My Three Shrinks".

This video documents some of the iPhone hysteria...

And speaking of hype, how often do you think the iPhone is paired with some sort of psychiatric symptom? Let's see...

• iPhone crazy: 2,440,000 hits
  
• iPhone addiction: 1,900,000 hits
• iPhone suicide: 1,810,000 hits
  
• iPhone madness: 1,620,000 hits
• iPhone depression: 1,520,000 hits
  
• iPhone mania: 1,500,000 hits
• iPhone paranoia: 1,030,000 hits
  
• iPhone obsessions: 710,000 hits
  
• iPhone hysteria: 475,000 hits
• iPhone delusions: 272,000 hits
• iPhone compulsions: 141,000 hits
• iPhone hallucinations: 121,000 hits
  
• iPhone anhedonia: 181 hits

Clearly, the iPhone is one of the coolest tech toys on the planet today. Lack of interest is definitely NOT going to inspire many hits.

EDIT: But it may inspire a new religion (Xenu beware).

Other blogs and links worth checking out:

• iPhone dissected
• quick review on Kottke.org
• Dave Winer not gushing
• Top 10 iPhone apps suck

EDIT: Must-see YouTube Chris Pirillo here, with an iPod and a Zune going at it under the covers ... Zune doesn't satisfy like iPhone (Warning: Graphic Gadget Adult Situations).

Google Health: Where's a Psychiatrist When You Need One?

Google has established an Advisory Council for health-related googling. There are 20-something people on the Council, but no nurses and no psychiatrists (as far as I can tell... at least, no one is clearly representing these constituencies).

Of course, you cannot put together such a group without others complaining that they didn't get a seat at the table. Make the table too big, and it is hard to get things done.

But, given the fact that one of the main medical areas that folks do searches about is psychiatry and mental health, they need a web-savvy shrink (I'll volunteer ;-). And nurses are the infrastructure that supports today's health care system. The U.S. system does need fixing, but would completely collapse without nurses. They need a seat, too.

Inspiring Grand Rounds at Wandering Visitor

Wandering Visitor has done a really great job with this week's Grand Rounds, with the theme of 'what inspires you', which in turn inspired us to write Fuel for our Fire.

And, now I know that those rainblow splashes you see, when the sun is high in the sky, are called "circumhorizon arcs". Now, I want to know the name of the other ones that occur around an hour or so before sundown (or after sunup), where you see two horizontal blips of color ( - - ), one on the left and one on the right. My recollection is that these occur when the sun is at an angle of 22 degrees, but I don't know the name or the physics behind it.

I Still Prescribe Seroquel But I Don't Get Paid To Do It.

Chapter 10 remains up at Double Billing. Thanks to those who've commented!

And don't forget to check out the ClinkShrink fiction venture at Double Celling!



From today's New York Times : PSYCHIATRISTS TOP LIST IN DRUG MAKER GIFTS. Great.

How this money may be influencing psychiatrists and other doctors has
become one of the most contentious issues in health care. For instance, the more
psychiatrists have earned from drug makers, the more they have prescribed a new class of powerful medicines known as atypical antipsychotics to children, for
whom the drugs are especially risky and mostly unapproved.

Vermont officials disclosed Tuesday that drug company payments to psychiatrists in the state more than doubled last year, to an average of $45,692 each from $20,835 in 2005. Antipsychotic medicines are among the largest expenses for the state’s Medicaid program.

Wow! Or maybe Oy! That's a lot of money, they don't say How Many Vermont psychiatrists see that kind of moola. One, two, ninety percent of those maple-syrup, Birkenstock-wearing Shrinks, or all of them?



So, for the record, last year I earned $0.00 from pharmaceutical companies. Funny, it was the same amount that I earned the year before and the year before that and the year before that. What am I doing wrong? Where's my 45 grand?



Full disclosure: I work in two different settings that serve indigent, often uninsured, patients. Some of the people I see in private practice have no health insurance. Atypical antipsychotics cost a lot of money. If you don't have health insurance, they remain pretty much inaccessible to many many people. So I'm nice to the drug reps, I chat for a few minutes, I sign for samples, sometimes I even call and request samples, I use their pens, and if you show up needing an antipsychotic agent, you get the one that's in the closet. I used to run a clinic, and part of that work entailed educational programs for the staff and boosting morale: go straight for the stomach. Sometimes I asked the pharmaceutical reps to provide lunch and they'd bring a tray of sandwiches. This went over well with the staff.



Do the pens and sandwiches influence what I prescribe? I can't say no for sure, but it feels like they all come, so what's to say which I use more? Really, boils down to my anecdotal evidence more than anything else: if the first time I try a med, the patient returns saying it helped, I'm more likely to use it. If I have to slowly titrate up and it takes a lot of time and a lot of appointments, I'm less likely to use it. Sorry, Effexor. If the first patient who tries it comes back ranting it was horrible, I get a bit colored. I talk to my shrinky-friends: are they having the same experience? If not, I'll reassess and try again. Even if I don't use the drug myself, I still smile at the reps, sign on the dotted line, and throw the samples in the closet for whoever else wants it.



So why aren't they paying me? Really, that post I wrote on Why I Still Prescribe Seroquel, shouldn't that be worth a few bucks? Look, I'm cheap, never mind the 45 grand, I'd have done it for a mere $20,000.



Finally, I need to say a few words about media sensationalism. Villainizing psychotropics seems to be the thing to do, and hell, get those docs who prescribe them while you're at it. I really wish that atypical antipsychotic medications didn't cause weight gain, diabetes, and metabolic problems. And now that I know this, I tell people. Many people don't develop these side effects-- I've become more diligent about checking labs and warning people of the risks. Though I really wish I could say that it's rare for people to develop diabetes either on or off these meds-- the truth is it's a really common illness and a lot of my patients have it before they see me, a lot get it during the course of treatment, and some get it during the course of treatment with atypical antipsychotic medications. If there was something else I could prescribe, I would and often I do. From my perspective of the doc-in-the-office, there sometimes is just no option but to use these medications, they're what we've got. This isn't to defend the drug companies, I believe their goal is simple: to make money. Kind of like your health insurer runs ads with soft music telling how they care, but really they just want to make money. What surprises me is that anyone expects anything else from them. No answers, sorry.



My last word about media sensationalism: It's hard to get Medicaid, you have to be sick. An episode of depression treated with Prozac doesn't do it. To get Medicaid, at least in Maryland, you have to be chronically ill (and even that isn't always enough), so a bad psychiatric illness, chronically, probably one that you need a chronic, expensive, antipsychotic medication to get. No wonder antipsychotics are a high percent of the Medicaid budget.

Okay, send the check, I'll be waiting

The Best of Intentions

First, the rest of Chapter 10 is up on Double Billing.

Really, in some ways, everyone is a little bit of a psychologist. People naturally look at their worlds and tell stories to explain what they see. Some people are more inclined to do so; they search for patterns, they find bits of evidence, they write the tale to make the pieces fit.



"Harvey is an introvert because he was bullied as a child."



Change the name, change the trait, change the cause, but we all do it. I can't tell you how many times a day I hear "I'm depressed because something bad (you fill in the event) is happening in my life." Or even, "I'm depressed because I've gained so much weight." Never mind that the depression came first, then the medicine to address the depression, and then the weight gain! Funny, but I don't generally hear, "I'm depressed because I have this illness." Okay, sometimes, but even in people with strong family histories, few precipitants, there is still a tendency to say "My brother is depressed because he sits in the house all day," rather than "My brother sits in the house all day because he's depressed."



Okay, so we're all out own psychologist, we all see cause and effect in others and ourselves. What strikes me most is that some people have a tendency to write their stories in terms of the untestable assumptions about the intentions of other people.



"He ignores me because he wants to make me angry." Or because he's jealous, or manipulative, or because people ignore me because they don't like me because I'm the wrong size, shape, color, religion.



How do you know? I often ask for evidence, and it pours in. Once someone has formed an idea about the intentions of others, the evidence supports the theory. A story is told that builds the hypothesis of meaness in the other person. I listen. Sometimes I say nothing (what's there to say?), other times I point out alternative reasons why someone could have done something so mean aside from their innate evilness. Bad hair day? Person was so wrapped up in their own stuff they didn't consider how it might impact someone else? Pure misinterpretation? Or simple inconsideration? When evil intentions are ascribed to total strangers who have no clear motive, I am particularly suspect of the stated intention. Maybe the guy in the car in front slammed on his brakes because his cell phone rang, or he realized he missed his exit, or there was something in the road, or he dropped the directions, and not because he wanted to make you swerve.



Am I right? Who knows. There are people out there who are purposely vengeful, and sometimes I can be a bit naive, unsuspecting, overly trusting. I want to believe that even if people are flawed, they are basically good, that their intentions were generally something other than to willfully cause pain. Funny thinking for someone who watches The Sopranos, Lost, and 24-- where evil is so central.



I think it helps people if they can clarify the intentions of others -- maybe even ask: Why did you do that hurtful thing?-- rather than create explanatory stories that may propagate painful myths. I'm fond of saying, "If he were sitting next to you, how would he tell the story?"



It's been a long day.
Oh, and I did the Double Billing link in green because Roy doesn't like the links in Red. It's because he has too many dopamine receptors in several areas of his brain.

My Three Shrinks Podcast 26: Black Box Reloaded

[25] . . . [26] . . . [27] . . . [All]

---

We again record this podcast in Dinah's backyard, with a guest cardinal who comments throughout the whole thing.

---

June 24, 2007: #26 Black Box Reloaded

Topics include:

• Side Effects of Psychotherapy. Sharon Begley from Newsweek wrote an article entitled, "Get Shrunk at Your Own Risk." We discuss this particularly in reference to grief and bereavement, PTSD, and CISD.
  
  
• Discussion at Cheryl Fuller's Jung at Heart about therapy as a treatment for an illness vs. as a tool to improve one's life. And here's an afterthought.
  
  
• The Impact of the FDA's SSRI Black Box on the Decline in Depression Treatment in Kids. We discuss the June 2007 AJP article by Libby et al. showing that there was a 58% drop in expected number of antidepressant prescriptions for this population after the black boxes went up, and that the proportion of depressed children who remained untreated with antidepressants increased some three-fold. Other data has showed an increase in the suicide rate if this population afterwards. In the graph below, the black line represents the percentage of kids with major depression who were prescribed no antidepressant.
  
• Q&A: "In my neck of the woods there is pretty much NO 'talk' therapy in short term inpatient settings. I know of many depressed individuals who have decompensated in these settings, and have had their depression actually increase on their departure. Any thoughts?"
  

The tune at the end is "Advice for the Young at Heart" from Tears for Fears, which you can get for less than a buck at iTunes.

---

Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Dr. Crippen, Blog Fodder

Oh he's done it now. He has truly done it. I have spent several years of my life working to become a doctor, only to have Dr. Crippen suggest that perhaps I and other women physicians don't have a right to certain specialties or job flexibility. He quotes a Dr. Sarah Blayney, who writes:

"The training jobs as they stand are all or nothing. You either do all the hours or don't get the post. I want to pursue a career in hospital medicine, which will mean me committing to a minimum of five years of fairly hefty on-calls. "

At the moment I am 24, single and am enjoying life. But in four or five years time my situation may have changed and I may not want to work those hours."

She said flexible working would be particularly relevant to female colleagues wanting to start a family, but said male colleagues were also interested in changing their hours. For example, some wanted to take time out to travel, she added."

Note that the need for flexible job hours is cited as a concern for both men and women. However, Dr. Crippen takes it upon himself to limit this issue to women:

"It is right and proper that women can pursue a career in medicine. But at what stage do we decide that the needs of medical training can no longer be subsumed by the needs of working mothers?"

Perhaps Dr. Crippen would do well to remember that not all women are, or are planning to be, mothers. Perhaps he would do well to remember that here are many other reasons for limiting on-call and extended working hours---like retaining one's sanity. But that's OK because he also suggests that: "Sarah lives in cloud-cuckoo land. She wants the job but she is not prepared to do the hours....You need to grow up a little.... Just because you are a girlie, you can’t expect medical training to be turned on its head."

Good God. I thought we had grown beyond that. I thought I had left thinking like that behind on my surgery rotation, along with the bra-snapping resident and the resident who once complained about me scrubbing in: "I found a medical student to help, but she's a girl." Given that over half of all medical students in training today are female, it's truly time for this discrimination to be over.

So please feel free to visit NHS Blog Doctor today and leave a comment. The only comment I have to say right now is: "Sic 'em!"


[From Clink: Sigh...she insists on modifying my post again...At least I can modify her awful color choice.]
Guess What? The first half of Chapter 10 is up on Double Billing.

FDA Drugs: March 2007

2007: Feb | Jan . . . 2006: Dec | Nov | Oct | Sep

---

FDA Drugs: March 2007

• Zenvia for "Involuntary Emotional Expression Disorder". Avanir Pharm received an "approvable letter" last October for its Zenvia, which is a combination drug of dextromethorphan/quinidine (DM/Q) used to treat what is otherwise known as labile affect or pseudobulbar affect, a brain condition where one will have uncontrollable bursts of laughing or crying without truly being happy or sad. This typically occurs after a stroke or with pseudobulbar palsy or ALS. The FDA had required more data, which the company recently provided at a meeting. The DM is an NMDA antagonist, and quinidine is being used here as a P450 CYP2D6 enzyme inhibitor, which makes the drug stick around longer. The FDA asked Avanir to resubmit a new NDA for a lower, safer dose.[PubMed]


• Cephalon gets yet another Warning Letter on Provigil. The FDA dinged Cephalon again in this Feb 27 letter about inappropriate marketing claims suggesting that Provigil is effective for certain conditions when these data have not been submitted or approved by the FDA.


• Marijuana-based Drug Gathering Data. Sativex is an oral spray containing two active compounds from the cannabis sativa plant being developed for several conditions, including MS-related spasticity, AIDS-related anorexia, and neuropathic pain. Given the fact that it is directly derived from pot plants and the U.S. paranoia about marijuana, I'm sure this drug has a long, uphill battle to get approved here. [PubMed]


• Prozac Labeling Change for Infants. The labeling information for Prozac/fluoxetine now has added info on the risk of Primary Pulmonary Hypotension (PPH) in drug-exposed newborns.
  

  PRECAUTIONS-PREGNANCY-NONTERATOGENIC EFFECTS. Infants exposed to SSRIs in late pregnancy may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN). PPHN occurs in 1-2 per 1000 live births in the general population and is associated with substantial neonatal morbidity and mortality. In a retrospective case-control study of 377 women whose infants were born with PPHN and 836 women whose infants were born healthy, the risk for developing PPHN was approximately six-fold higher for infants exposed to SSRIs after the 20th week of gestation compared to infants who had not been exposed to antidepressants during pregnancy. There is currently no corroborative evidence regarding the risk for PPHN following exposure to SSRIs in pregnancy; this is the first study that has investigated the potential risk. The study did not include enough cases with exposure to individual SSRIs to determine if all SSRIs posed similar levels of PPHN risk.

  I don't know if all SSRIs will get this language. The link goes to the original NEJM article.
  


• New FDA Info Sheets on:
  

Invega/paliperidone


Keppra/levetiracetam


Trileptal/oxcarbazepine

• Permax Recalled. The FDA announced that the dopamine agonist, Permax (pergolide), has been voluntarily recalled due to concerns about damage to heart valves. Permax was used to treat Parkinson's disease and restless legs syndrome.


• Phase III Trials Started on Flurizan for Alzheimer's. This looks like a promising drug from Myriad to keep track of.
  


• Geodon Label Updated. The labeling info for Geodon (ziprasidone) was updated in the Patient Summary section, to include the black box warning about diabetes and also include the more recent indications for manic and mixed episodes of bipolar disorder.
  


• Symmetrel Label Updated. Apparently, there have been some reports of agranulocytosis (dangerous drop in White Blood Cell WBC count) with Symmetrel (amantadine), which is used as an antiviral, for Parkinsons, for pain, and probably a few other things. The labeling info now reflects this.
  


• FDA Adds Warnings on All Sleeping Pills. The FDA has asked that all makers of sedative-hypnotics, like Ambien, Sonata, and Lunesta, add warnings to their labels about (1) anaphylaxis (severe allergic reaction) and angioedema (severe facial swelling), which can occur as early as the first time the product is taken; and (2)
  complex sleep-related behaviors which may include sleep-driving, making phone calls, and preparing and eating food (while asleep). The warning affects the following 13 drugs and their manufacturers:
  

  Ambien/Ambien CR (Sanofi Aventis)
  Butisol Sodium (Medpointe Pharm HLC)
  Carbrital (Parke-Davis)
  Dalmane (Valeant Pharm)
  Doral (Questcor Pharms)
  Halcion (Pharmacia & Upjohn)
  Lunesta (Sepracor)
  Placidyl (Abbott)
  Prosom (Abbott)
  Restoril (Tyco Healthcare)
  Rozerem (Takeda)
  Seconal (Lilly)
  Sonata (King Pharmaceuticals)

Fuel For Our Fire

Wandering Visitor, a very positive-thinking resident who is running Grand Rounds next week, is looking for posts on what inspires us (see also Why Do I Blog?). So we thought we'd have a go at this. We are three psychiatrists from three different perspectives (prison-based forensic psychiatry, outpatient psychiatry both private and clinic-based, and hospital-based consultation-liaison psychiatry) who blog and podcast about stuff that captures our interest.

---

Clinkshrink:
At the risk of sounding oppositional (who, me?), I'm inspired by my co-bloggers particularly when I disagree with them. Fortunately they remain my friends in spite of this. Friendly disagreement is a wonderful source of intellectual growth and mental stimulation.

I'm also inspired by any topic that gives me a chance to talk about what it's like to work in a correctional facility, care for inmates or generally care for those who aren't able to care for themselves. I think it's important to remind people that you can't "lock someone up and throw away the key" and forget they exist. I'm here to talk about what happens within the walls.

I like the unusual and the off-beat; I blog about cannibals and insanity acquittees and human sacrifice and write travelogues about my favorite historical prisons. Occasionally I try to be relevant to my forensic training by reviewing topics like the Tarasoff duty and sex offender commitment laws.

Occasionally I ramble about ducks and that really floats my boat. My co-bloggers are very patient with me.

---

Roy:
This "what inspires me" bit puts me at risk of getting sappy and melodramatic. To minimize this risk, I will switch into Outline mode...

• sunsets
• injustice
• Mother Nature
• space
• ants
• Boolean logic
• Stephen Hawking
• "Uncertain Smile" (The The)
• "Bario Alto" (Thievery Corporation)
• the smell in the air after it rains
• Leo Laporte
• Monty Python
  

Alright, that's enough of that.

---

Dinah:
Sadly, the first thing that came to my mind when I thought about What Inspires Me is: Good Food. Why? How? I don't know, it just does. I'm hoping that I don't miss out on too many Hot Fudge Sundaes in the name of healthy living and the never-ending quest to be a size smaller.

Goals of any type inspire me. I'm slow and steady with good endurance, but I've never had any speed. ClinkShrink runs 9 minute miles, Roy's wife does half-marathons. I decided I should be able to run: just one 10 minute mile. Then 2 miles in 20 minutes. I've hated every second of it and I'm convinced that the longer, slower, uphill trek was better for me, but hey, I did it. Why? Why not. So trying to get my latest novel published is a goal, and by all means, drop by Double Billing and comment on my fiction. I had to get that plug in.

My husband, my children, my dog Max, and the wonderful friends I have in my life all inspire me often. ClinkShrink, Roy, and Camel are among the most inspiring. My patients are often inspiring and I wish I could write blog posts about some of the brave and amazing people I see.

L.A. E.R. Tragedy . . . Emergency Mental Health Care

Connect the dots between these two stories...

Dr. Cory Franklin has a Commentary in the Chicago Tribune about this tragic story of a lady who died in an L.A. E.R. waiting room with bystanders calling 911 to help her because she couldn't get help in the ER.

Shortly after another bystander made a second futile 911 call imploring paramedics to take Rodriguez to another hospital, she died of a perforated bowel. A security videotape, still unreleased to the public, is said to show her writhing on the hospital floor unattended for 45 minutes. At one point, the tape reportedly shows a janitor going about his business mopping the floor around her.

. . .
This should be the audio of the 911 call... [removed due to misbehavior... try this link to listen: Youtube]


Mary Beth Pfeiffer in yesterday's Huffington Post discusses our broken mental health system.

In the 1990s, Virginia built 18 new prisons and closed 1,400 mental hospital beds. Across America, state spending on prisons spending tripled in the last 25 years while spending on mental health care rose by about a fifth.

And if you thought the era of shuttered hospital beds was over, consider that America lost another 57,000 psychiatric beds from 1990 to 2000. As a result, from 1992 to 2003, American hospital emergency rooms saw a 56 percent increase in people experiencing psychiatric crisis. It's time to stop the bloodletting.

Where is our compassion, our humanity, our duty?

Mental Illness and the Right to Vote.

Oy. From yesterday's NY Times: States Face Decisions on Who is Mentally Fit to Vote:

“I just think if you are declared insane you should not be allowed to
vote, period,” said Joseph DeLorenzo, chairman of the Cranston Board of
Canvassers. “Some people are taking these two clowns and calling them disabled
persons. Is insanity a disability? I have an answer to that: no. You’re insane;
you’re nuts.”

Rhode Island is among a growing number of states grappling with the
question of who is too mentally impaired to vote. The issue is drawing attention
for two major reasons: increasing efforts by the mentally ill and their
advocates to secure voting rights, and mounting concern by psychiatrists and
others who work with the elderly about the rights and risks of voting by people
with conditions like Alzheimer’s disease and dementia.

Can I cringe long and hard now? The mentally ill shouldn't vote? What's a mental illness? Anyone who's had an episode of depression or mania? Obsessive Compulsive Disorder? How about those panic attacks? And we can't figure out at what instant someone with dementia becomes unsafe to drive, how do figure out the instant at which they should stop voting? Anyone confined to a psychiatric facility? Anyone getting disability payments for a psychiatric disorder?

Dumb people can vote. Illiterate people can vote. Republicans can vote. Ugly people can vote. Why should the mentally ill have a standard different from anyone else's?

From The NYTimes: When is a Pain Doctor a Drug Pusher

Oh, no, I did it again, I posted over Roy! I swear, I didn't know. Scroll down for his post.


We like to talk about subjects where the lines get blurry. Who should get care? When is it an illness? Xanax? Seroquel? Which side of the fence and how far over might one lean?

So here's an interesting cover story in the Sunday New York Times Magazine: When is A Pain Doctor A Drug Pusher?

It's the story of a pain doctor who has been sentenced to 30 years in prison for his sloppy and questionable prescribing practices. The article's author, Tina Rosenberg, comes at it with the tone that it's outrageous that he was sent to jail, deemed a criminal, for his lax practice. Bad doctoring, she contends, is cause for civil malpractice litigation, not criminal prosecution. The docs who prescribe in exchange for sex or drugs, they are the criminals. The doctor in the story did none of those things. She makes the point that the standards for prescribing narcotics, especially to a chronic and drug-tolerant population of pain patients (who may be peppered with occasional abusers) are purposely not stated, and leave the doctor open to both scrutiny and criminal charges.

There are red flags that indicate possible abuse or diversion: patients
who drive long distances to see the doctor, or ask for specific drugs by name,
or claim to need more and more of them. But people with real pain also
occasionally do these things. The doctor’s dilemma is how to stop the diverters
without condemning other patients to suffer unnecessarily, since a drug diverter
and a legitimate patient can look very much alike. The dishonest prescriber and
the honest one can also look alike. Society has a parallel dilemma: how to stop
drug-dealing doctors without discouraging real ones and worsening America’s
undertreatment of pain.
* * *
But such guidelines are futile while there is one pain specialist for,
at the very least, every several thousand chronic-pain sufferers nationwide. And
even though pain is an exciting new specialty, doctors are not flocking to it.
The Federation of State Medical Boards calls “fear among physicians that they
will be investigated, or even arrested, for prescribing controlled substances
for pain” one of the two most important barriers to pain treatment, alongside
lack of understanding. Various surveys of physicians have shown that this fear
is widespread. “The bottom line is, doctors say they don’t need this,” said
Heit. “They’re in a health care system that wants them to see a patient every 10
to 15 minutes. They don’t have time to take a complete history about whether the
patient has been addicted. The fear is very real and palpable that if they
prescribe Schedule II opioids they will come under the scrutiny of the D.E.A.,
and they don’t need this aggravation.”

By the time I finished this article, I was glad I'm not a pain doc. I was even more glad I'm not a pain patient.