Welcome to ICD-10

Today is October 1, 2015, and the day set for the long-awaited change in the system used to code medical and surgical diagnoses.  Say good-bye to the 17,000 ways that the International Classification of Diseases 9 let you be sick or injured, and now we have 70,000 new ways for all those events.

In psychiatry, it shouldn't be too bad, and I'm planning to spend my day in the office updating my computer.  The psychiatry blogger PsychPractice was kind enough to make a cross-over chart, and I'm hoping that will be helpful.  If it might be helpful to you, here is the link:

http://psychpracticemd.blogspot.com/p/blog-page.html


For others, it may not be such an easy day.  If you're having angioplasty today, yesterday your doctor had a choice of one code.  Today, she has 845 options, so do be patient with her, it's a big menu to choose from.  

There were jokes on Twitter about codes that would differentiate between being bitten by a duck in a thong or being bitten by a duck while wearing a thong.  Here at Shrink Rap, where the duck has been our long-time mascot, we don't think that's at all funny.

If you'd like a sample of some of the new codes, however, there is something for everyone.

For the creative types:
Y93.D1 Activity, knitting and crocheting

For the more active souls:

V91.07XA Burn due to water-skis on fire, initial encounter

 For those who can be a bit klutzy:

T71.231D Asphyxiation due to being trapped in a discarded refrigerator, accidental.  I couldn't find the code if someone was trapped in a refrigerator that hadn't been discarded.

And for those who are just really unlucky:

V9542XA Spacecraft crash injuring occupant – 

The codes can be very specific:

S30.867A Insect bite (nonvenomous) of anus, initial encounter

And we don't want ClinkShrink to feel left out, so there is

Y92.146 Swimming pool of prison as the place of injury

(And I imagine ClinkShrink will certainly be spending her day checking on the safety features of all those swimming pools in the correctional system here in Maryland)

Finally, there really are duck-related injury codes and they are kind enough to differentiate whether the patient is struck by a duck W6162XA or bitten by a duck W6161XA.  I suggest that you not do anything to provoke the duck.

Humor Alert brought to you by Rachel Griffin, graduate student

Sh*t People Say to People with Mental Illness

#GiveStigmaTheBoot

In case you missed it, the billboard above, sponsored by designer Kenneth Cole, has been the source of a lot of angst.  Presumably, Mr. Cole meant to point out that people with difficulties have trouble accessing mental health care ( ~so true), but instead the message blames people with mental illness for gun violence.  It's both wrong and stigmatizing, and the American Psychiatric Association understandably asked to have the billboard taken down and started a #GiveStigmaTheBoot campaign.

I want to point out an inconsistency in the APA's endorsements.  Representative Tim Murphy has proposed an overhaul of our national mental health services from the top down.  Many of Murphy's proposals in his Helping Families in Mental Health Crisis Act are admirable and have the potential to decrease repetition of oversight, and hopefully to change the way psychiatric services are delivered to those who need them most.  However, the bill was put forth in response to the Newtown tragedy where a disturbed young man killed 27 people, including 20 young children.  Murphy repeatedly says that something needs to be done about our nation's mental health services before more such tragedies occur, and that this is his promise to the parents of the children who died at the hands of a disturbed gunman.

Murphy's bill creates incentives for court ordering patients to outpatient treatment, also called Assisted Outpatient Treatment or AOT -- a measure that has been used in some states for people with psychotic disorders who are repeatedly hospitalized for noncompliance with treatment.  Outpatient commitment is a tough one -- it may help some people to get help, but it also infringes on a person's right to determine their own medical care, a civil right we all value.  
  In an article in Behavioral Healthcare on September 4, 2015, "Murphy touts mental health bill on Cleveland visit," Julie Miller writes about Murphy's support of the controversial outpatient commitment bill.   Miller writes:

He believes that if the perpetrators of violent tragedies like Sandy Hook Elementary School and the Aurora, Colo., movie theater had assisted outpatient treatment, the tragedies wouldn’t have occurred. To those who oppose AOT on the basis of personal freedom, he says, “Go talk to the moms from Sandy Hook and tell them that.”

Personally, I'm at a loss here.  From what I've read in a variety of sources: the media, the report of the Connecticut Department of the Child Advocate, and live-streamed testimony from the Aurora hearings, neither of those shooters had ever had a single psychiatric inpatient commitment and neither had a history of violence.  No one knew these young men had planned these atrocities.  The graduate student in Colorado was going voluntarily to treatment, he stopped when he left school and his eligibility for services ended.  If his psychiatrist knew he was dangerous, there are laws in place that would have permitted his commitment.  Both young men were diagnosed with anxiety disorders, not psychotic disorders, prior to their shocking crimes.  Simply put, they weren't candidates for Outpatient Commitment, and by making the assertion that outpatient commitment can prevent mass murders, the implication is that the government could knock on your door to see if you are harboring a loner young man who plays videogames and behaves oddly.  These aren't the people who get captured by Outpatient Commitment orders.

Yes, we need better mental health access and more comprehensive services.  But we need them to help people live better lives and suffer less.   Everything about Murphy's Bill as a promise to the parents of the children of Newtown --- that better mental health services will prevent mass murder -- is stigmatizing.   And yet the APA has no campaign against this stigmatizing bill, in fact, the APA wholeheartedly endorses this form of stigma.  

Follow Up on Parity and Tuition Reimbursement Insurance

I recently wrote a post about the discriminatory practices by Dewar Insurance -- a company that offers insurance for tuition reimbursement in case illness prevents a college student from completing the semester.  For some schools, the reimbursement is less and the standard of proof is higher if the illness is a mental disorder. 

The issue was originally brought to my attention by Maryland psychiatrist (and parent) Dr. Mark Komrad, author of  the book, You Need Help, wrote back with what he learned at freshman orientation at his son's college.  

A couple of weeks ago I discovered the lack of mental health parity in the tuition reimbursement insurance available through my son's college. And a few of us did research and found this parity problem common to many colleges, including in Maryland, but not all. Withdrawals for mental health reasons have tuition reimbursement at a lower percentage than "medical" withdrawals. Also, unlike medical withdrawals, mental health withdrawals require two days of hospitalization as part of the eligibility criteria to pay out.

I'm moving my son into college, and had a meeting about this with the directors of Student Accounts and a representative from the Dewar insurance company, the underwriters. I thought I would share some notes from that informative meeting:

• -My son's school is on top of this issue and next year the tuition reimbursement insurance will have full parity for mental health, WITHOUT requirement of hospitalization!!!

• -No family at this college has ever complained before about lack of parity until I raised this--neither prospectively as now, nor when a policy had to be used for mental health reasons! So there was no incentive to change, although the fairly new director of student accounts was troubled and was already taking initiative to change it before I got involved

• -Only about 100 families buy a policy, most don't think they'll ever need it. So there is much interest here and elsewhere in making the policy automatically included as part of the bill next year, but with an option to opt-out. Like with all insurance, the more people who participate, the less expensive the premiums are.

• --There has been a steep rise in withdrawal for mental health reasons nationally just in the last 4-5 years. The majority--about 70%-- of health withdrawals nationally now are for psychiatric reasons. Prior to that they were the minority reason. Nobody is quite sure why that is.

• -Dewar would actually like to offer parity policies but many colleges have not been interested. Again, this is not a particularly popular product so colleges haven't paid much attention to the non-parity status quo that goes back several decades. Many are just starting to notice the non-parity issue now, and are moving to correct it. Dewar is happy to try and make that possible for any of its college customers.

• --This policy places NO extra financial risk on colleges. That is NOT the reason colleges haven't sought parity.

• -Dewar doesn't really challenge doctors notes vigorously. Docs have to fill out a form. There are no internal  "medical consultants" that review and deny coverage--unlike health insurance companies. With the policies that require psychiatric hospitalization, that requirement has been waved in many cases.  It's a holdover from many years ago when these policies were first crafted.

• -For the business model to work for parity,  psychiatric (now the most common cause for intra-semester withdrawal) and medical can't BOTH be covered at 100%. So policies that now cover medical at 100% and psych at 60% will need to be restructured for the two the meet in the middle. Losing that 100% for medical may be one of the inhibitors to change

So, if we are going to go after this parity issue in Maryland, my sense is that it needs to be on a college by college basis to increase their consciousness about this issue, and, for those who have contracted with Dewar, to let them know that this can be potentially corrected.

Provigil: the drug that helps you perform better

There is an article in the Atlantic called "The Rise of Work Doping" that talks about Provigil (modafinil) as a medication that enhances cognition with very few side effects. Medically, we use it to treat narcolepsy -- the uncontrollable urge to fall asleep. But I've also seen patients on it for depression -- often a desperation measure prescribed during a hospitalization. In terms of cognition and motivation, I haven't seen it do amazing things -- maybe the patient has more energy and functions a little better, but it's been no panacea for low motivation or cognitive jump-starting. There's a caveat here:   I've used very little of it for a very practical reason: the medication cause roughly $1000 for 30 pills (give or take a couple of hundred) and it's not a drug that insurances are eager to approve.

 I'd like to tell you something about the practice of psychiatry, or at least about my practice. I see a fair number of patients with mood disorders, and the mood disorders are often pretty easy to treat. The symptoms generally resolve (no, not for everyone, but a for a lot of people). And while many people get better and return to work and to a meaningful, active life, there are some people who stay stuck in a life they are disappointed with despite the resolution of the depressive symptoms. They remain unmotivated (especially for things they don't enjoy doing), may not return to work or do so in notably under-employed ways, and can find it hard to accomplish even little things, like cleaning up a bedroom or closet, or plowing through a to-do list, or organizing a vacation, or coping with a broken car/iphone/computer.   Or perhaps their moving along okay, but they aren't happy with their lives the way they are and just can't seem to do what's necessary to get life to change.

Often these people also have issues with attention to detail and organizing their lives.  They forget appointments, lose their keys and phones, and have trouble planning ahead: what we call Executive Function.  While stimulants may help these folks with concentration and energy, they don't seem to do much for helping with organizational skills.   So while I'm not interested in giving Provigil to healthy executives who want a raise, I am interested in knowing if you have tried it with your patients with Executive Dysfunction, and if it's been helpful to them?

What happened to Parity? Dewar Insurance discriminates against people with mental health disorders.

 

A colleague wrote into our psychiatric society's Listserv --  his son is starting college and he was solicited to purchase tuition reimbursement insurance in case something goes wrong and his son needs to withdraw.  He was surprised to read that the company offered one amount if a student withdraws for 'medical' reasons and another, lesser percentage, if the student withdraws for 'mental health' reasons.  Oh, and the medical leave needs a doctor's note, while a mental health leave requires that the student must have been hospitalized for two consecutive days for the psychiatric condition.  

That seemed outrageous, and it occurred to me that I have a kid in college and I had the same offer for tuition reimbursement insurance sitting in my spam.  Only my offspring is at a different university in a different state and there is no medical vs. mental health differentiation for her large university.  I clicked on a few schools and concluded this was a quirk of my colleague's son's institution.  He was quick to point out that I was wrong -- colleges and universities are all over the map with this, and I soon realized that every school that offers this policy in Maryland has some inequity for mental health reasons-- either a lesser amount of reimbursement or a requirement for hospitalization.  I don't quite understand -- are they saying that mental illnesses are less real or valid so you have to 'prove' you're really sick, and by the way, you get less of a refund?  Disability of all varieties has the potential to be an individual matter especially when it involves pain or fatigue.  And in Maryland, our governor has set the bar quite high -- he was recently diagnosed with an aggressive form of lymphoma and is undergoing chemotherapy -- certainly a good reason to take some time off -- but his photo (minus hair) is in the paper every day with his declaration about some topic or other.  At some level, a doctor of any specialty is left to trust the patient (or not) when he says he just can't do something because he's in too much pain, too tired, too depressed, or his preoccupation with delusions and hallucinations is getting in the way.  

The company mentioned is Dewar -- you can look up a university they cover here: College Tuition Refund - Home Page, but apparently it's been an issue for years.  Below I'll post some articles about the issue from The  New York Times and Psych Central.  It's disheartening that despite this outcry and confrontation in 2011, Dewar continues to have these discriminatory policies.  I couldn't find anything that indicated that NAMI or APA were part of the conversation, but I could well have missed it (~please let me know if I have).  In the comments section on the third article, one person noted that when she complained to Yale's president, then the policy did change to one of equal coverage, but it seems like a war of many small battles which are mostly not being fought.  In addition, I'm posting a link to an excellent summary about why parity legislation has not resulted in the changes that were hoped for.  

In the NYTimes: Tuition Refunds, but Not Quite on Equal Terms

On Psych Central:

Sallie Mae, Markel and Dewar Discriminate Against People with Mental Illness  

And more in the NYTimes (read the comments)

How Tuition Refund Insurance Works at Your School

And, finally, for anyone interested in an overview of how and why parity is failing, this is an excellent summary, from earlier this month:

Congress tried to fix mental health care in 2008. Lawsuits charge it isn't working.

And, no, I don't want to talk about why the background is green.  Where is Roy when I need him?

 

Flipping the Switch

Last week I met with Dr. Irving Reti to talk about brain stimulation as a psychiatric treatment.  Irving is the editor of a new book, Brain Stimulation: Methodologies and Interventions and he happens to be a stimulating guy to chat with.   He divides his brain stimulation into 'convulsive' -- that would be ECT or electroconvulsive therapy -- and 'nonconvulsive' : transcranial magnetic stimulation, transcranial direct-current stimulation or tDCS, and deep brain stimulation).  I wrote about our conversation over on the Clinical Psychiatry News website and please do click over to "Catching up on brain stimulation with Dr. Irving Reti".  I was particularly interested in tDCS which Irving likened to hooking yourself up to a 9-volt battery and he mentioned that the machinery -- not intended to treat psychiatric conditions -- is readily available at  http://www.foc.us/.  He also recommended a very interesting New Yorker article, Electrified, by Elif Batuman, which talks about an anesthesiologist in Georgia who uses tDCS to treat patients, and himself, for depression .

So with electricity on my mind (not literally, or at least not yet), today I noticed an article on The Carlat Psychiatry Report talking about the use of both transcranial direct and alternating currents

for the treatment of depression, and in "Fisher Wallace and Alpha-stim for Depression," Gregory Sahlman and Jeffery Borckardt talk about the differences between sending direct versus alternating current through the brain and the evidence for both of them.  Apparently the alternating-current device (made by Fisher Wallace) can also be self-administered, and costs a bit more. Stimulating stuff, be the bottom line is that there hasn't been enough controlled research to know if all this electricity works.

And by all means, if you have your own stimulating stories to share, please post them in the comment section below.

Does Watch-Your-Words Political Correctness in Universities Contribute to Mental Illness?

There's an interesting article in The Atlantic about how we now coddle college students by avoiding certain ideas -- and even certain words -- that might be offensive to someone.  The article talks about certain words/ideas being 'microagressions' and that professors offer 'trigger warnings,' if course material might remind people of past traumas.  

In The Coddling of the American Mind, Greg Lukianoff and Johnathan Haidt write, "Last December, Jeannie Suk wrote in an online article for The New Yorker about law students asking her fellow professors at Harvard not to teach rape law—or, in one case, even use the word violate (as in “that violates the law”) lest it cause students distress."  Wait, so we think our top lawyers should not be educated about rape law?  Who will prosecute or defend the rapists?

The list of what might be offensive is long and sometimes a bit oblique for me, and I have to say, I wonder about first amendment rights to free speech (or any speech), when the topics come down to things such as this:

During the 2014–15 school year, for instance, the deans and department chairs at the 10 University of California system schools were presented by administrators at faculty leader-training sessions with examples of microaggressions. The list of offensive statements included: “America is the land of opportunity” and “I believe the most qualified person should get the job.”

America may or may not be the land of opportunity, but if a college professor truly believes that, he can't say it?  And (*beware, possible micro-agression in the rest of the sentence*), I'm totally lost as to what is wrong with expressing the personal belief that the most qualified person should get the job.  

The authors write:

The press has typically described these developments as a resurgence of political correctness. That’s partly right, although there are important differences between what’s happening now and what happened in the 1980s and ’90s. That movement sought to restrict speech (specifically hate speech aimed at marginalized groups), but it also challenged the literary, philosophical, and historical canon, seeking to widen it by including more-diverse perspectives. The current movement is largely about emotional well-being. More than the last, it presumes an extraordinary fragility of the collegiate psyche, and therefore elevates the goal of protecting students from psychological harm. The ultimate aim, it seems, is to turn campuses into “safe spaces” where young adults are shielded from words and ideas that make some uncomfortable. And more than the last, this movement seeks to punish anyone who interferes with that aim, even accidentally. You might call this impulse vindictive protectiveness. It is creating a culture in which everyone must think twice before speaking up, lest they face charges of insensitivity, aggression, or worse....

Today, what we call the Socratic method is a way of teaching that fosters critical thinking, in part by encouraging students to question their own unexamined beliefs, as well as the received wisdom of those around them. Such questioning sometimes leads to discomfort, and even to anger, on the way to understanding.

But vindictive protectiveness teaches students to think in a very different way. It prepares them poorly for professional life, which often demands intellectual engagement with people and ideas one might find uncongenial or wrong. The harm may be more immediate, too. A campus culture devoted to policing speech and punishing speakers is likely to engender patterns of thought that are surprisingly similar to those long identified by cognitive behavioral therapists as causes of depression and anxiety. The new protectiveness may be teaching students to think pathologically.

The authors contend that over time, parents have become more concerned with safety, from bullying which might contribute to mass murders, to peanut butter bans, to unsafe playground equipment.  Children have learned that the world is an unsafe place and adults will provide protection.  

Read the article, because the examples go on and on, one includes a hearing against a young man who was disciplined for reading a book about the Klan (specifically about how a college protested the Ku Klux Klan) because the picture on the cover offended another student.  

The authors go on to note: 

Because there is a broad ban in academic circles on “blaming the victim,” it is generally considered unacceptable to question the reasonableness (let alone the sincerity) of someone’s emotional state, particularly if those emotions are linked to one’s group identity. The thin argument “I’m offended” becomes an unbeatable trump card.

 Furthermore, they contend that avoiding discussion of certain topics is not helpful to people with problems and may create pathology in those without them:

However, there is a deeper problem with trigger warnings. According to the most-basic tenets of psychology, the very idea of helping people with anxiety disorders avoid the things they fear is misguided. A person who is trapped in an elevator during a power outage may panic and think she is going to die. That frightening experience can change neural connections in her amygdala, leading to an elevator phobia. If you want this woman to retain her fear for life, you should help her avoid elevators.

But if you want to help her return to normalcy, you should take your cues from Ivan Pavlov and guide her through a process known as exposure therapy. You might start by asking the woman to merely look at an elevator from a distance—standing in a building lobby, perhaps—until her apprehension begins to subside. If nothing bad happens while she’s standing in the lobby—if the fear is not “reinforced”—then she will begin to learn a new association: elevators are not dangerous. (This reduction in fear during exposure is called habituation.) Then, on subsequent days, you might ask her to get closer, and on later days to push the call button, and eventually to step in and go up one floor. This is how the amygdala can get rewired again to associate a previously feared situation with safety or normalcy.

Students who call for trigger warnings may be correct that some of their peers are harboring memories of trauma that could be reactivated by course readings. But they are wrong to try to prevent such reactivations. Students with PTSD should of course get treatment, but they should not try to avoid normal life, with its many opportunities for habituation. Classroom discussions are safe places to be exposed to incidental reminders of trauma (such as the word violate). A discussion of violence is unlikely to be followed by actual violence, so it is a good way to help students change the associations that are causing them discomfort. And they’d better get their habituation done in college, because the world beyond college will be far less willing to accommodate requests for trigger warnings and opt-outs.

The expansive use of trigger warnings may also foster unhealthy mental habits in the vastly larger group of students who do not suffer from PTSD or other anxiety disorders. People acquire their fears not just from their own past experiences, but from social learning as well. If everyone around you acts as though something is dangerous—elevators, certain neighborhoods, novels depicting racism—then you are at risk of acquiring that fear too. The psychiatrist Sarah Roff pointed this out last year in an online article for The Chronicle of Higher Education. “One of my biggest concerns about trigger warnings,” Roff wrote, “is that they will apply not just to those who have experienced trauma, but to all students, creating an atmosphere in which they are encouraged to believe that there is something dangerous or damaging about discussing difficult aspects of our history.”

The authors conclude, for a number of reasons, that shielding students from potentially controversial or upsetting words and ideas is wrong -- it leaves them too thin-skinned and it creates an intellectual environment of homogeneity.  What's the answer? The authors conclude that college students should all be taught Cognitive Behavioral Therapy to help them deal with uncomfortable ideas.  The whole article was great food for thought, although the idea that we are stifling intellectual innovation and exploration for fear of using a word that might offend someone, well it makes me kind of uncomfortable. 

Adventure in Peru

I have to tell you: I had the most incredible summer adventure in Peru.  Yes, it was part vacation, coordinated mostly by a friend who is a native of the country and was able to show a group of us the country with a native's insights, and that alone was fabulous.  But the other part of our trip was a volunteer medical mission in the Andes, outside the beautiful city of Cusco.  If you'd like to read about my experience on this mission, I'll invite you to read today's post over on Clinical Psychiatry News: Single Session Psychiatry at 11,000 feet. 

Your Kidneys or Your Sanity: Two Bad Options

There's a article in the New York Times by Jaime Lowe titled, "I don't believe in God, but I believe in Lithium."  I had no idea the two were mutually exclusive or even had anything to do with one another!  The title aside, I liked the article. 

Lowe describes devastating bouts of psychotic mania, and how lithium enables her to lead a functional and productive life, with mental illness held at bay.  Until her renal function starts to tank. 

Lowe writes:

I wanted a calmer life. So for the next 13 years, I took my three pink capsules and all was well. I wrote a book, I learned how to cook in an Italian-restaurant kitchen, I had a few relationships that lasted longer than a month, I wrote, I boxed, I traveled, I painted, I took my pills. I was fine.

Then, last fall, I saw my primary physician — and he sent me to the nearest emergency room. He was alarmed at my combination of high creatinine levels, damaged kidneys and heart-attack-level blood pressure (185/130). At Mount Sinai Hospital, my doctor’s fears were confirmed in a matter of days: My kidneys were irreparably damaged, an ‘‘uncommon but not rare’’ side effect of long-term lithium use. I was told I could phase out lithium and start another medication, or face dialysis and a kidney transplant in 10 years.

It doesn’t really feel like an obvious choice; it just feels like two bad options. Switching meds might mean the return of cornrowed, Eminem-obsessed Jamya and many seasonal gourds. Yet tubing up and cleansing my blood until I get a stranger’s kidney quilted into the rest of my insides is hardly more appealing. Test results indicate that my kidneys are working about half as well as they should; Maria DeVita, a nephrologist at Lenox Hill Hospital, told me that if I am to switch to preserve the kidney function I have left, ‘‘the time to strike is now.’’

Wishing her luck coming off, and I hope it turns out that there is a third and fourth option that work as well for her.

He's still just like someone without mental illness, only more so.

I wanted to share this wonderful essay with you.  It's by Mark Vonnegut, and you may remember the review I wrote and how I loved his memoir, Just Like Someone Without Mental Illness, Only More So. 

This is an essay posted on KevinMD, "A doctor shares his story about overcoming mental illness"  and do surf over to read the whole thing. I promise you'll be moved.  

Here's a part of Dr. Vonnegut's writing: 

In my career as a mental patient, I started with schizophrenia, worked my way up through manic depression, and have now settled at bipolar disorder. I can joke about it because I recovered sufficiently to get into and through medical school, internship, and residency, and have had the enormous honor and privilege of being trusted by parents to help them and their children. I make no bones about it; I make mistakes just like everyone else, but am very proud of how well I do my job.

I’m also very aware of how easily I could have ended up otherwise — a suicide statistic or just another broken young man who never got well enough to have a life.

The diagnosis doesn’t matter much. What they think you have can give doctors a clue about what to do or not do, but for the person who is suffering, and for those who love him or her, wanting the pain and trouble to stop is enough. Knowing that others have recovered is very helpful; most patients, including myself, have diagnosed themselves as hopeless more than once.

He goes on: 

The reverse is also true; just because you don’t hear voices, doesn’t make you a model of mental health. One of the problems with mental health diagnosis is how reassuring the process is to “so-called normal” people. The sub-text to me having a thinking disorder is that your thinking is fine. I freely admit that I have an affective disorder, and find the idea that my feelings are more than a little off-base a huge relief — but to jump from my affective disorder to the conclusion that your feelings make perfect sense is just illogical.

There are all kinds of statistics, but the bottom line is that no one among us is 100 percent crazy, and no one is 100 percent sane. The chance that you or someone you love won’t need help at some point with what we broadly call “mental illness” is 0.

And finally:

There ain’t no difference between them and us. We’re all here to help each other through this, whatever it is.
There’s almost always something positive you can do; the problem is believing in that possibility, and letting others help you figure out what it is.

 

Join Us at 9 PM EST for a Tweet Chat on Social Media in Medicine

Dr. Margaret Chisolm was the recent guest editor for International Review of Psychiatry's edition that was devoted to social media in medicine.  The issue is open at no cost for the month of June and the Shrink Rappers all contributed--
http://informahealthcare.com/toc/irp/27/2#/doi/full/10.3109/09540261.2015.1027672

Tonight, some of the contributors will be involved in a Tweetchat on the uses of Social media in medicine.  Do join us:

Swapnil Hiremath, MD ‏@hswapnil 2h2 hours ago

#SoMe for #Meded, advocacy - 'the three shrinks' http://informahealthcare.com/toc/irp/27/2#/doi/full/10.3109/09540261.2015.1027672 … by @clinkshrink @HITshrink & @shrinkrapdinah #nephjc

1 retweet 0 favorites

Dressing the Part

 


The New York Times has a rather interesting opinionator piece by Dr. David Hellerstein called "The Dowdy Patient."  Hellerstein talks about the frustration of treating a lovely woman who longed for a relationship but was notably 'dowdy.'  I'm chopping pieces from Hellerstein's essay below:

A boyfriend, then marriage, and soon after that, kids — that was pretty much all that Greta felt was missing from her otherwise enviable existence, which included Ivy League degrees, a Wall Street career, a downtown loft....

For more than a year, Greta and I met once and sometimes twice per week for psychotherapy and medication treatment....The only area of her life that didn’t improve was romance. Not that she didn’t go on dates, but they typically were one-off events. There never seemed to be a spark, much less a flame.

One day, after a bit of hemming and hawing — I knew it would be a sensitive topic — I raised the obvious: Had she considered getting a makeover? One of her friends, as Greta herself had told me, had recently seen an “image consultant” who recommended a whole new wardrobe, new hairstyle, different makeup. Could that, I asked, possibly be helpful?

Years of psychotherapy training had given me no guidance in how to deal with the staunchly dowdy patient.

But advice about the patient who refuses to be attractive? No.

Maybe a female or gay male therapist would have had an easier time addressing this topic with Greta. But for me, as a straight male working with a straight female patient, every option seemed blocked. Basically, no matter how I tried to put it, I would be saying, “I find you unappealing.”

Which, at least to Greta, would have raised the reasonable question, Why on earth would she want me to find her appealing? The whole thing reeked of grossness.

Psychotherapy is about helping people to see the patterns in their life so that they can make changes.  But it's not about telling people they look awful.  And just the thought of a male psychiatrist telling a female patient to have a make-over makes my skin crawl.  Indeed, it reeks of grossness.  Of note, the first time that Hellerstein brought up the idea with his patient, she stopped him in his tracks -- she told him she dresses up to go out on weekends and her friends say she looks great.

I wanted to write about this, however, because I could relate to Hellerstein's frustration.  I don't have a dowdy patient, but I felt  Hellerstein's awkwardness and difficulty bringing up the elephant in the room --the elephant that seems to exist for one person, the therapist in this case.  While I don't have a dowdy patient, I have had patients whose issues-- whether inappropriate attire or inappropriate anger -- have clearly gotten in their way. For example, one man always wore very dark sunglasses inside and didn't understand why people wouldn't talk to him at social events (remember, somewhat confabulated here) then dismissed my concerns when I suggested that maybe people would like to see his eyes. 

 In these stories, it's really not a therapist's job to say "Have you considered deodorant?" or  perhaps dressing like the person you want to be (employed, sexy, respectable) -- these are things people should hear from friends and relatives, and the truth is that they've all heard it, and often it seems they just don't want to believe that it's actually part of the problem.   And since therapy isn't about having someone scream at a patient that it really is the dowdy clothes sending the wrong message ---(and perhaps the patient does look great on dates and the dowdy clothes aren't the reason for the lack of relationships....), well...these things...be they dowdy clothes, or an off-putting personality trait that the patient doesn't want to acknowledge...make for tough times in psychotherapy.

 

Is Psychiatry Monolithic? Can You Rule Out Mental Illness By Reading Someone's Journal/Sketchbook? And, The Murphy Bill Returns

A few things from around the web:

In The Myth of Monolithic Psychiatry, Dr. George Dawson takes on the question of "Is Psychiatry Monolithic?"  I didn't know what that even meant, but now I do, and this is a terrific piece and well worth the read.

Over on the Marshall Report,  former APA president Jeffrey Lieberman gives his opinion on the notebook the Aurora shooter mailed to his student counseling center psychiatrist before he killed innocent people in a movie theater.   Based on his review of the notebook, Lieberman was able to conclude:

His chief complaint and reason for seeking help at the university health center was related to interpersonal issues and anxiety. He does not reveal what would be considered psychotic symptoms. The major issues are his alienation, disaffection, isolation, fear and anger. No mental disorder is clearly apparent. 

Wait, do psychiatrists do that -- rule out the presence of a mental illness -- without so much as meeting the patient?  I guess I missed that part of training.   I'd also like to add as an aside that while I have no idea if the shooter had a psychotic illness or was responsible for his actions (alas, I've never met him), I do think that intense psychic pain should fall under the rubric of what psychiatrists treat even if the symptoms don't add up to meet the DSM Chinese menu criteria for a specific mental disorder. 

And the text for the 2015 version of the Helping Families in Mental Health Crisis came out on Thursday.  The text of the new congressional act is 173 pages long, nearly 40 pages longer than the last version.  Pete Early did a stand up job of getting right on it and comparing the new bill to the 2013 text in  Murphy Introduces Revamped Bill.  Outpatient Commitment is apparently no longer required, but states who adopt it will get extra funds, which I guess I find less objectionable, sort of.  And there are some limitations on ending privacy rights for psychiatric patients which I think might do a better job of serving the intent of loosening these requirements.  I'm still not a fan of singling out psychiatric patients as the only people who can't instruct a doctor not to release information about their care.  And finally,  I'm not sure how Murphy is planning to make more psychiatrists -- our field is already in a shortage situation, and psychiatrists are aging out of the field, with the majority of psychiatrists who are currently in practice now being over age 55.  Personally, I think the only way to get more people into the field is to subsidize medical school for those who go into the field.  As it stands now,  many medical students just can't take on the astronomical educational debt and still manage on a psychiatrist's pay.  

I'm still not sure I support the new version (Oh, I haven't read it and don't know if I will) but this does seem better.  Do check out Pete's post.

And to those who've commented on our decreased rate of blogging, rest assured that we're making good progress with our upcoming book on involuntary psychiatric treatment.



T

Medicare Spending on Mental Health is Up! And Why is This a Surprise?

In today's edition of USAToday, there is an article titled Mental Health Spending is Up, New Medicare Data Shows.  

The article notes:
Medicare providers got more for mental health and specialty care including sports and sleep medicine in 2013, according to new payment data released Monday that shows which healthcare providers received the most money.
Among the biggest changes:
• Spending on psychiatry was up 9.3%, to $853 million

Okay, so I want to point out that in 2013,  psychiatry changed how we code and there was the introduction of new CPT codes.  At the time, the complexity and absurdity of breaking down minute-by-minute break down of each session into psychotherapy versus evaluation/management seemed absurd, but we all eventually fell into breaking our appointments down into a set of codes that captures what we do.  It meant that bills sent to Medicare reflected an E/M portion plus a psychotherapy portion, and the result was a much higher amount that could be billed/charged then under the old "50 minute psychotherapy with medication management code."  

So if you suddenly increase the amount that a service is compensated, why is it surprising that mental health spending went up?  Just sayin' .....