Why Am I Asking All These Questions?

I'm reading a book where the shrinky author starts off with a revelation: it's not the best care to see patients for a 50 minute evaluation, start a medication, have them come back in a month for a 15 minute med check, and refer them to a social worker for psychotherapy. It does sound like a good way to make a lot of money. If you aren't totally exhausted, overwhelmed with the phone calls and paperwork you must have seeing that huge a case load, and are someone who is gratified from this type of work, then it's cool by me. It's not what I want to do.

The author trained at about the same time as I did, and trained at an institution with a biological orientation, like the one I trained out. He talks about this kind of care as though it's standard and the usual and expected. I've never heard this as standard, and in my private practice, I see new patients for 2 hours, and want people to come back weekly for 50 minute sessions until -- they are no longer symptomatic, or they've gotten what they want out of the treatment. Some people come into treatment without symptom---their old shrink moved or died, and they just want a script and someone to rely on if they get sick. I don't insist they come every week, but I'll ask them to come more frequently than they are used to coming for a little while until I feel like I know them. Some people can't afford weekly psychotherapy or find it to be a burden, and I often respect their wishes to come less frequently, unless their illness is destroying their ability to function, in which case I think they need to come weekly. I don't see anyone more than once a week (unless there is an emergency) routinely, and I never seem to have patients who come requesting twice weekly therapy sessions. Almost everyone comes for the full 50 minute session. A few people who just aren't talkers come for half hour sessions.

I've worked in a number of community mental health centers. I know some clinics have huge caseloads and a full-time doc may have 500-1000 patients. I've never worked anywhere like this. Most of the clinics I've worked in have left the frequency of visits up to the doc, though certainly there is a clinic tone. In one clinic I worked in, most patients saw the doc once a month, where I work now, it's once every three months for patients who are stable. The therapist attends those sessions, and they may be quite brief....many of the patients don't seem to want to talk, and the paperwork burden imposed by the regulatory agencies are very heavy. Still, the standard at all the clinics I've worked in is 2 patients an hour. The no show rate is high, and sometimes a 3rd patient may be squeezed into the schedule if there is a scheduling problem.
My record is 15 patients in one day, and this was while I was volunteering at a clinic in Louisiana after Katrina, and the clinic had no full time doctors and a huge demand. It was 15 patients I'd never seen before, some were quite troubled, and it was a tiring day for me. So my hat goes off to those docs who see 4-6 patients an hour. I couldn't do it.

So what is the standard? I thought I'd ask. Of our readers, it looks like many see their psychiatrists weekly and many see them for 50 minute sessions. Just thought I'd ask. Thank you for taking my surveys and please do add your comments.

How Long Do You See Your Psychiatrist For?

Again, just psychiatry visits, not sessions with a non-MD therapist. Thank you and I'll explain soon.

How Often Do You See Your Psychiatrist?

If you haven't take our poll on Why You See A Shrink, then please do! This is just for fun, it's not real science.

So today is Sigmund Freud's birthday. He would be 154 years old.

Today's poll asks How Often Do You See Your Psychiatrist---and I'll ask that you limit your answers to psychiatrists-- M.D.'s or D.O's-- so if you see a non-psychiatrist therapist for therapy, and a psychiatrist for meds--I mean the med check person, and if you're in psychoanalysis with a psychiatrist, I mean the couch person. But I'm not interested in how often you see your social worker/psychologist--- maybe another day.

Why Do You See A Psychiatrist?

People see shrinks for a variety of reasons. These days, I think people come mostly for treatment of psychiatric disorders--also called mental illnesses-- like depression, bipolar disorder, anxiety, schizophrenia. But people come for other reasons. Sometimes they have personality styles that aren't working for them, or they have behaviors that they troublesome, like drinking too much or using drugs or gambling. Some people want to understand themselves better and use therapy for this purpose. Others need help coping with major losses or stresses.
Most of these issues do fall under the categories of psychiatric disorders--- so someone with a maladaptive personality disorder or a behavioral problem will fit into a diagnostic category, but with respect to the types of treatments offer, there aren't medicines for all of these, and in some cases, therapy gets a bigger role. So if you've seen a psychiatrist, I'll ask why. I'll have more questions later. Thank you for participating.

My Name is Dinah and I am an Addict

From The Huffington Post, here is an article on people with PDA addictions. I can relate. Only I can relate pro-actively. I knew the first time I saw email that it would ruin my life. I kept it in my office, but I found myself wanting to go to work to check my email. Eventually, I surrendered and brought it home. It ruined my life.

I don't have internet access on my cell phone or PDA. Why? Because I check it all the time. I check it in traffic. I check it when I'm on line at the grocery store. I check it after I check it. Repeatedly. What am I looking for? Does it matter? It's bad enough that I'm glued to my laptop at home.

I don't have internet access in my office. No, I'm not kidding. I'm there to be at work, and I'm supposed to be with my patients. If I had a computer, I'd be peeking at email, waiting for time between patients to check, to blog, to plug in.

Huffington writes:

We realize that this is a widespread malady. Consider these stats:

• In 2009, the average American watched more than 151 hours of TV a month -- an all-time high
• 84% of people check their PDAs just before bed and as soon as they wake up -- and an astounding 85% peek at their PDAs in the middle of the night!
• One survey found that over a third of smartphone users would pick their BlackBerry over their significant other if they had to choose one to live without!

If all this sounds like addiction, well, it probably is. In a new study, college students who went 24 hours without using any media -- no cell phone, iPod, TV, etc. -- then blogged about their experience, using terms of addiction to describe their feelings: in withdrawal, frantically craving, miserable, jittery, crazy.

I can relate.

Health Care Reform and Mental Health--stolen from Kevin MD

Who could follow the Obama Health Care reform debates? Thousands of pages and emotions flying high, and it all became a partisan fiasco, where the patients got lost in the reams.

So Kevin MD --- links to How Heath Care Reform Will Affect Mental Health-- a post by blogger Diane Lee at Somebody Heal Me. It's a hopeful and optimistic post about how reform will increase the number of insured, increase access to treatment and medications, shrink donut holes, prevent insurance companies from refusing to insure those with mental illness, and do overall good things for the country. I like optimism.

Are you feeling hopeful?

Just the Facts, Ma'am

In The Data Driven Life in today's New York Times Magazine, Gary Wolf writes about people who track their activities in fine detail. Coffee or alcohol consumption, calories, menstrual cycles, ideas, time spent cleaning up after roommates---you name it, it can be tracked, and the online life makes it oh-so-easy. If you've got obsessive compulsive tendencies, this may be heaven, or it may drive you over the edge. And of course, there are some practical applications for psychiatry. Wolf writes:

Jon Cousins is a 54-year-old software entrepreneur and former advertising executive who was given a diagnosis in 2007 of bipolar affective disorder. Cousins built a self-tracking system to help manage his feelings, which he called Moodscope; now used by about 1,000 others, Moodscope automatically sends e-mail with mood-tracking scores to a few select friends. “My life was changed radically,” Cousins told me recently in an e-mail message. “If I got the odd dip, my friends wanted to know why.” Sometimes, after he records a low score, a friend might simply e-mail: “?” Cousins replies, and that act alone makes him feel better. Moodscope is a blended system in which measurement is supplemented by human sympathy. Self-tracking can sometimes appear narcissistic, but it also allows people to connect with one another in new ways. We leave traces of ourselves with our numbers, like insects putting down a trail of pheromones, and in times of crisis, these signals can lead us to others who share our concerns and care enough to help.

The point of the article? Other than a long-winded way of saying, Hey, look what folks are doing! I'm not so sure there was one. And while you're keeping track, Victor took second place in the salsa contest (the dip, not the dance).

Please Pass The Chocolate

This is for Victor, who sent us the link to a CNN article looking at mood and chocolate consumption: Chocolate and Depression Go Hand and Hand by Denise Mann. So here's the scoop, people eat more chocolate when they are depressed. Mann writes:

Although gorging on chocolate and sweets to beat the blues has become a cliché thanks to sitcoms and romantic comedies, there's been "little prior scientific literature linking chocolate and depression," says the lead author of the study, Dr. Beatrice Golomb, a professor of medicine at the University of California at San Diego School of Medicine. The study, she says, provides evidence to support "the popular perception that when people need a pick-me-up, they pick up chocolate."

It's unclear, however, whether depressed people eat more chocolate simply because they crave it, or whether chocolate consumption itself somehow contributes to a depressed mood.

In the study, Golomb and her colleagues surveyed more than 900 people about their weekly chocolate consumption and their overall diet. They also gauged the moods of the participants using a standard questionnaire used to screen for depression. (People who were taking antidepressants were excluded from the study.)

It's not really clear from the article if the article is talking about people with transient sadness or people with clinical depression, but if there's any link between chocolate and emotional states, then we're happy to link to it on Shrink Rap.

Victor: may your salsa win the contest this weekend. And I don't want to hurt your feelings but I've never been able to eat that chocolate bacon bar you gave me.

We're All Going To Die

I heard Irvin Yalom speak today. He's a psychiatrist/writer/ very famous shrink at Stanford, and he was at Johns Hopkins today to give the Jerome Frank lecture. The title of his talk was "Staring at The Sun: Overcoming the Terror of Death." It's also the title of his latest book. The auditorium was packed---no surprise here. When I heard Dr. Yalom was coming, maybe a month ago, I made a point to block off the time to be there-- I've never heard him speak and I was looking forward to this. Please let me share the experience with you.

Dr. Yalom is a gifted writer. He writes about his work in colorful and accessible ways, and he speaks about it this way as well. He lectures an audience of hundreds as though he is talking to a single friend. No notes, no hesitation, and he seems so at ease as he talks openly about work that is quite intimate. His specialties are group psychotherapy and existential psychotherapy, and he classifies the existential issues as death, isolation, freedom (as in freedom to make decisions and to steer the course of one's life, not political freedom), and meaning. "We are unfortunately meaning-seeking creatures heralded into a universe that has no meaning." Now he tells me!

Dr. Yalom started by talking about Dr. Jerome Frank (for whom the lecture is titled)--one of his mentors --and talked about a poignant visit with him near the end of Dr. Frank's life. Dr. Frank was also one of my psychotherapy supervisors, perhaps at a time in my training when I took such things for granted and had no true appreciation of what an amazing gift it was to be his student. Dr. Yalom talked about his memories, and I revisited my own.

Dr. Yalom talked about his own psychotherapy experiences: his three years in psychoanalysis in Baltimore "There was so much attention to the distant past and so little to the future and our death." Later in life, in California, he spent two years in therapy with Rollo May.

Death anxiety, Yalom contends, is an issue for many people--one patients won't necessarily bring up on their own, one they avoid if they sense the therapist is uncomfortable, one that, indeed, makes therapists uneasy as they, too, have their own death anxiety to face. Perhaps it's easier to avoid the topic; after all, there's nothing to do about it. We're all going to die. The therapist, he says, has a role in discussing death, and therapy can diminish the anxiety.

He talked a little about his work with cancer patients and how facing death can have a transforming effect; people get a better sense of priorities. "What a pity I had to wait until now to learn how to live," one dying patient told Dr. Yalom.

By far, the most interesting parts of the talk were when Yalom talked about specific examples of his own work with patients and the interactions that transpired. He talked about a patient--a psychotherapist--- who asked him about his own death anxiety (he responded) and who talked about his concerns about how Dr. Yalom might judge him. One nice thing about being Irvin Yalom is that you can get up in front of an audience of hundreds and talk openly about your work, boundary violations and all. He ended with the statement, "To become wise, you must listen to the wild dogs barking in your cellar." --a version of a quote by Nietzsche. I'm still thinking about that one.

It's been a while since I've heard a lecture like this. We've become so focused on psychiatry as the treatment of illnesses, of which drug at what dose, for how long, or which type of psychotherapy, and certainly we assume that what goes on in therapy includes talking about issues that having meaning to patients--including things that evoke anxiety, and the nuances of life that include meaning. We know we talk about these things behind closed doors--but we don't often talk about the process of such transactions.

My Three Shrinks Podcast 52: The Friendly Skies

In Dinah's post Fly Those Friendly Skies she talks about the new FAA policy regarding pilots on antidepressant medication. We found out something about pilot life span. Retired pilots live five years longer than their non-flying peers.

We talk about the New York Times article In Therapy: Cell Phones Ring True. The article discusses what therapists learn about their patients through their cell phone conversations and pictures.

Roy introduced us to the Lanny-yap blog, where we found a picture of Roy's dog, Eddie. This blog has a reference to a Scientific American article on anisomycin, an experimental medication that has been used in rats to wipe out fearful memories. Shades of Eternal Sunshine of the Spotless Mind (2004)!

Finally, we talk about a prospective study of 16,000 adults who started college and tried to guess which psychiatric diagnoses were most associated with failure to complete college. The full study can be found in the April edition of Psychiatric Services.

Once again, we talk about our upcoming book. We still need a title we can all agree on. Help us out by sending ideas to mythreeshrinksATgmail.com!

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This podcast is available oniTunes or as an RSS feed orFeedburner feed. You can also listen to or download the .mp3or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening

Send your questions and comments to: mythreeshrinksATgmailDOTcom

More on the Electronic Monster

We like to bicker about Electronic Medical Records here at Shrink Rap. They give Roy's life meaning. Clink and I are more ambivalent.

In An Unforeseen Complication of Electronic Medical Records, Dr. Paul Chen (NY Times, April 22nd) writes about trying to pay attention to the patient and the computer at the same time:

“EMRs are a phenomenal contribution to care,” said Dr. Ann S. O’Malley, lead author of the study and a senior researcher at the center. But there is often so much information available — some of which requires a direct and immediate response from the physician — that “some doctors liken the presence of EMR to having a 2-year-old in the exam room.”

As all parents can attest, while a 2-year-old can create chaos in any situation, a setting that is as delicately balanced as the clinical one runs the risk of falling into complete disarray. Doctors often must consider several issues simultaneously when seeing a single patient — all the potential diagnoses and possible treatments, the patient’s history and list of medications, any possible adverse effects or interactions, the limits of that patient’s health care coverage and numerous preventive health issues, to name just a few of those considerations. The addition of an electronic records system can push some doctors into what one EMR expert refers to as “cognitive overload.”

“The whole point of EMR is to simplify the process and to enhance and facilitate communication,” Dr. O’Malley said. “But in order for that to happen, EMR needs to be more user-friendly and more responsive to the clinical needs of patients and clinicians.”

Happy Blogiversary to Us!

Shrink Rap is Celebrating FOUR YEARS today!

Peeps, we gotta go out to eat! And no, Roy, you may not bring a sauerkraut banana cream pie.
-this is our 1,211th post-

She likes it! She likes it!

Do you remember the cereal commercial where everyone shoves a bowl of cereal at the dumb little brother to watch for his reaction? Mikey won't like it, he hates everything! But surprise, Mikey does like it!

We sent the final chapters of the draft of our book to our editor. So far, the process entails a bounce back, and sullen words like "this isn't working"...and then a lot of obsessing, a re-write, and finally we get to, "this is much better." It's become a bit of a joke--we build in time for her to hate it.

This Sunday, I stayed in my pajamas. I sat in front of a computer all day long. I didn't go out. I was ironing out the kinks in the last two chapters. Roy...well, I knew he was trying to write because he was commenting on old blog posts and he opened a new Facebook account. Why? I was ready to scream. I told Editor and ClinkShrink which day to reserve for Roy's funeral and to get their suits out. Roy didn't get it, he informed me he would be out of town that day and could go to a funeral on Sunday. Maybe he did get it.

Put the suits away. 12:30 AM and Roy's chapter was sent to our editor. Mine were sent a few hours earlier. Much quicker turnaround than usual: She likes them! I feel like those little kids when Mikey likes the healthy cereal.

I'm taking a moment now to just be happy.

Meet Prozac Pilot

Prozac Pilot!
Collin Hughes gave up his career as a pilot so he could get treatment for depression. He has a blog. He's now on the CNN home page. Watch his 'Coming out of the Hangar' video:



On CNN, Jeanne Meserve and Mike M. Ahlers write:
Meet Collin Hughes, a one-time rodeo cowboy turned jet pilot turned fledgling insurance agent, whose hope of returning to the sky has been reinvigorated by the new FAA policy. And who now hopes his story will embolden other pilots to address their depression.

Watch Me!

In the March issue of the Journal of Graduate Medical Education there is a paper entitled "How Residents View Their Clinical Supervision: A Reanalysis of Classic National Survey Data". This paper presents the results of a 1999 survey of 3,604 PGY 2 and PGY 3 residents. (The "PGY" refers to "post-graduate year", in other words how far along the physician is in her training after medical school.) The residents in this survey represented a random sample of 14% percent of all physicians in training, and almost two-thirds of the residents responded to the survey.

The good news is that the majority of the residents felt they had adequate supervision during their training.

Unfortunately, about a quarter of the residents reported that they had seen patients without adequate supervision at least once a week. Five percent said this occurred almost daily. Residents in opththalmology, neurology, neurosurgery and psychiatry were more likely to report inadequate supervision, while residents in pathology and dermatology were least likely to experience this.

Poorly supervised residents reported many other problems with their training programs, all of which could affect patient safety. Residents without adequate supervision also reported increased use of alcohol, significant weight change, or use of medications either to stay awake, to help them sleep, or to help them cope with the residency. They were also more likely to report higher ratings of self-assessed stress, sleep deprivation, total weekly work hours, and having worked while in an impaired condition. They were also more likely to report that they personally had been belittled and humiliated, or physically assaulted while working. In spite of all this, there was no correlation between sleep-related medical errors and being named in a malpractice suit.

Recently the Institute of Medicine issued a report with recommendations to reform graduate medical education. The report emphasized the connection between a healthy working (or training) environment and safe patient care. Surprisingly, medical organizations have not widely welcomed this. Certain specialty organizations are concerned that duty hour reform may deprive residents of valuable training experience and that the financial burden of duty hour reform will drive up the cost of health care. What this survey highlights is the fact that failure to adequately supervise residents and to provide humane working conditions creates a risk for the young physician as well as the patient.