The Final Report on the Germanwings Tragedy

Over on Clinical Psychiatry News, I have an article up on the final report about the Germanwings pilot who crashed the plane into the French Alps.  A sad topic, but do read it.

Guest Blogger Dr. Thomas Franklin Writes About His Own Experiences With Major Depression and Why He's Doing A Triathlon

Becoming an Ironman for Myself and My Patients

The sliver of light coming under the door of the windowless office seemed unbearably bright and offensive. I turned away from it and closed my eyes. There is a flat spot on the back of my head that, if angled just right, would lie on the textbook I was using as a pillow. In a few moments, I would be asleep again. I was supposed to be out seeing patients, but it was all I could do to show up at work and hide in my office. My supervisor was a gentle woman who would come check on me a couple of times a day. She would crack the door and ask, “Dr. Franklin, why don’t you come out and see one of the new patients?” 

“I can’t. I just can’t... I’m no good to anyone.”

Drifting in and out of consciousness in that dark room seemed far superior to being up and about, feeling the pain that seemed to emanate from my chest and flow throughout my body. It was as if my blood had been replaced by some impossibly dense material that could barely flow, making every step I took an effort. If I didn’t lie on that floor and feel my body supported all the way from that flat part of my skull to the small of my back, to the backs of my ankles, it felt like I might fall through to the center of the earth, through the dirt, rock, and then to the molten core where I would be incinerated. I wondered if that might be better than living like this.

Fearing Stigma but Seeking Help

I was a psychiatric intern at the time, and I was depressed. But I couldn’t bring myself to seek treatment. I suffered like that for months until I saw a colleague in consultation, where I described suffering the symptoms of attention deficit disorder, but suggested that a third-line medication for that diagnosis, also used for depression, might help me. I needed so much more than that medication, but my depression, my own inhibitions, and stigma kept me from getting the help I needed. Difficulty concentrating seemed a safer problem to admit to than depression. I was worried that I wouldn’t be taken seriously as a psychiatrist if it became known that I, too, was a patient. 

I continued to suffer off and on for years, finally getting into real treatment for the first time after my training was over. A combination of psychotherapy and medications led to the relief of stabilization. Ultimately, psychoanalysis, a more intensive therapy experience, helped me to fundamentally change how I thought about myself and the world, which led to not just relief, but a transformation of how my mind worked. Eventually, I was able to stop taking medicines. The way I had felt only years before seemed so far away. I felt a part of the human race. 

Until now, I have kept quiet about my experience. A continued fear of stigma has kept me quiet. I felt that if I was known as a psychiatric patient, even a so-called “cured” one, I would be labeled or disgraced or stereotyped. I thought it might hold back my career.

But the only way to combat stigma is to speak out. This is not easy, but I am inspired by those that have travelled before me on this road and by my current patients. I can’t go on urging them to be courageous, to face down the stigma they were feeling, without doing all I can to fight stigma myself. Only by shining the light of truth on people’s lived experience of mental illness will stigma finally become a thing of the past. 

Why a Triathlon?

After my psychoanalysis was over, I took up triathlons. Exercise has not only helped my mood, but I found that endurance sports are a powerful metaphor for what living with a mental illness can be like. In some ways, training for and finishing races makes me feel that I have mastery over that part of me that suffered so much.

In triathlons, like in depression, you have to go on putting one foot in front of another for as long as it takes. It will be painful. Your best-laid plans will go awry. Small mistakes early in the race can turn into big problems before the end of the day. The finish line will seem an impossibly long way away. There are moments of despair, but also moments of triumph. There is beauty around the next corner that can give you hope, if you only look up long enough to take it in. But preparing for and finishing the race is much more about your mind than your body. 

On July 24^th, I will be racing the 140.6 miles of the Ironman Lake Placid triathlon to fight stigma, to show people that are suffering that treatment works, and to raise money for the Sheppard Pratt Patient Care Fund so that no one has to go without the treatment they need. 100 percent of the monies donated to this fund are spent on patient care. Maybe someone we help get treated will become the next courageous voice in the fight against stigma. Please give generously, whatever that means for you in your life. Thank you for your support.

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Dr. Thomas Franklin is the medical director of The Retreat at Sheppard Pratt. He is a clinical assistant professor of psychiatry at the University of Maryland School of Medicine and a candidate at the Washington Center for Psychoanalysis. He is Board Certified in Addiction Medicine and Psychiatry, and has extensive experience in psychotherapy, psychopharmacology, and addictions and co-occurring disorders. Dr. Franklin previously served as medical director of Ruxton House, The Retreat’s transitional living program, before assuming the role of medical director of The Retreat in 2014.

Finding Help

Yesterday, I was a speaker at the University of Maryland's Cultural Diversity Day.
The theme was Urban Trauma: Understanding Its Impact and Navigating Access to Mental Health Care. I thought I would share some of my slides with our readers.  And now I know how to put a PowerPoint Presentation into a blog.

Listen to ClinkShrink Discuss Physician Assisted Suicide on the Radio

In case you haven't heard, our ClinkShrink has strong feelings about legislation to allow Physician Assisted Suicide.  She has written about it Here and Here.

A few weeks ago, ClinkShrink was on the radio talking about proposed legislation in Maryland.  She did a great job. 
Here's the link, you can listen to the whole show hosted by Sheila Kast.

http://wypr.org/post/aid-dying-debate#stream/0

To Aetna: I am NOT in your network

Dear Aetna,

I would contact you directly, but believe me, I've tried. 

Perhaps you could help me.  I am a psychiatrist is Baltimore and somehow my name is on Aetna's provider panel.  I never filled out an application or request with Aetna and I have no desire to be on their panel.  Over the last couple of years, I had gotten a few calls from prospective patients, clarified that I am not an Aetna provider, at least not willingly, and left it at that. Recently, the calls have escalated to as many as 5 a week.

I have called Aetna repeatedly, and I can't seem to find a voicemail option that allows me to speak with a human.  I received a call (left as voicemail) from Aetna the other day saying I must refund a patient because I charged more than the allowable rates for an Aetna-cover patient, and the  patient told them I was not in network, and a number was left for me to call. When I dialed that number, the automated answer machine knew who I was (I suppose by my phone number?) but then none of the prompts led to an option to discuss network participation or to speak with a human.  I have also gone to their website, where there is a place to report network issues, and I reported there that I am not in network and never heard anything.  I googled the Chief Medical Officer and tried to call him, without success.  This is a lot of time and effort to dis-enroll from a company I had never enrolled with!  Even your contact page is a fiasco.

  Network inadequacy is an enormous problem for patients and Aetna makes it extremely difficult to address.

What Do The Kids Need to Know?

That's a great title for a post, isn't it?
Unfortunately, this isn't going to be about anything all that juicy.  I'm giving a talk on Access to Care next week to 60 or so psychiatry residents in training.  I thought I would ask our readers: What should young psychiatrists know about finding a psychiatrist?  Are there things that make it harder or easier to find someone?  What should they know about health insurance participation?
Write something I hadn't thought of  and I'll read it at my presentation!
Thank you for your help.

What Your Psychiatrist Should Be Doing....

First, I'm going to send you over to read Pete Earley's blog post for today: Treatment Rather Than Punishment In Horrific Case But What Can We Do in the Future? 


So just to recap, this terribly tragic case is about a mother with schizophrenia who stopped going to treatment, became psychotic, put her three-year-old son on a swing and pushed the swing for 40 hours.  The boy died and the mother was found pushing her dead child in a swing.  The judge determined that she was not criminally responsible, and she is being mandated to treatment and allowed to stay in the community if she abides by the terms of her release.  This is an unusual outcome, usually if your child dies because of negligence or abuse, you go somewhere-- if not a prison then a forensic hospital.

So the question comes up as to whether this child's death could have been prevented, who is to blame, and how do we keep such things from happening in the future?  According to an article in the Washington Post, the mother had been admitted to a psychiatric unit in February of 2015, was discharged to outpatient care and was seen at a clinic in April of 2015.  She was diagnosed with schizophrenia.  She took medications and had stopped them only days before the tragic event in May.  The father had pursued full custody of the boy, but the parents ended up with joint custody.  The patient lived with her mother and son in a hotel. 

So Mr. Earley looks at the question of who is to blame. Is the adult patient's mother responsible? No, he contends, parents are limited in what they can do to help an adult child with a mental illness.  Should the hospital be responsible for making sure everyone goes to outpatient appointments months after discharge? No, that is too much to ask.  Social services? Too under-staffed.  And then I got to this sentence:

If someone is taking psychotropic medicine, the doctor who issued that medication should be obligated to monitor his patient.

What does that mean and how does that play out?  As a psychiatrist, when we hear the word "monitor," we think of assessing the patient to make sure the medication is appropriate, that side effects are being monitored (and hopefully minimized) and that recommended blood-work is being done.  I guess I could ask Pete what he meant by this, but instead I wanted to write a blog post.  It does seems like everyone else gets a pass -- the parents, the hospital, social services (~did they have a role?  Who exactly is social services anyway?).  But the psychiatrist should be obligated to monitor the patient.  No passes here.

So let's talk for a moment about the logistics.  A patient goes to a clinic and sees a psychiatrist and a social worker for therapy.  She stopped taking her medications, but there is nothing here about missing an appointment.  Should the doctor be watching patients swallow the pills?  Some people get sick even when they do everything the doctor says, our treatments help but they aren't perfect.  What if a patient who has been hospitalized doesn't show up at an appointment?  Actually, in community clinics, approximately 30% of appointments are not kept and it's possible that the doctor could be scheduled to see 12-25 patients each day.  He or she may call a patient who doesn't show up, but probably not-- it happens numerous times a day.  If a patient does not call to reschedule, eventually, the chart gets tagged, and the therapist calls or writes a letter to the patient saying that if he does not come in by a certain date, his case will be closed.  There is not a mechanism in our system for aggressive pursuit of patients. In fact, many clinics discharge patients if they miss 3 appointments in a row.  In outpatient settings, people are free to say they've decided they don't want treatment, they've decided to go elsewhere, they'll call when they want to come in. Just because someone has had an episode of mental illness-- one that required hospitalization-- it does not mean that we have a mechanism to insist they continue in treatment if they aren't in the criminal justice system --which this woman now is. 

What about Outpatient Commitment, or AOT as some call it -- would that have saved this child?  Well, we don't have it in Maryland, but even if we did, this parent was not repeatedly hospitalized, and she had voluntarily gone to care at the clinic the month before.  Even if we had laws for this, she would not have qualified.  And outpatient commitment is not a guarantee of safety: patients may disregard the orders, or get sick between appointments.

What about a system which includes very easy access to care and outreach service for all patients who have had an episode of illness severe enough to require hospitalization?  Maybe that would have helped, and if you agree, please do send your dollars to fund it because the expense would be astronomical. No where has this.

I don't know the details of this case and the press often reports selectively, so I don't even want to venture a guess as to what may or may not have prevented this tragedy.  I do think that there are some tragedies that we simply have no way of predicting.    

Hotel California

Our group of psychiatrists have a listserv -- it's a wonderful tool for sharing resources and keeping everyone up to date about the latest in professional issues.  From time to time, a discussion will ensue, and one psychiatrist posted his thoughts about patients who want to change psychiatrists.  I thought our blog readers might want to weigh in, and with permission, I'm reprinting that doctor's thoughts.  

Regarding taking patients who want to switch doctors, I have my own particular thoughts about that. Psychiatrists are a very scarce resource these days. Therefore, people who are able to have a psychiatrist are the fortunate  ones. Also, like so many of us, I'm pretty booked so I do not have that many openings to take new patients. So I prefer to use those scarce openings for people who don't already have a psychiatrist. Also, people who want to switch psychiatrists very often are having difficulty communicating with their docs about what's not working for them in their treatment. Or, there are transference issues that have not yet been worked through. Or, any one of another impasses in the treatment alliance. Or, they are on an ineffective medication regimen and the treating psychiatrist hasn't been able to ascertain alternative approaches-- pharmacological or otherwise.  So, I am always available to do a one-time second opinion consultation for such dissatisfied patients. Those consultations  provide a diagnostic reevaluation,  perhaps new ideas about treatment alternatives, recommendations to enhance communication, and observation of psychodynamic issues that might be relevant to the stalled recovery and/or treatment relationship.  I identify aspects of their doctor's practice that could be modified to make for a happier patient (e.g.  returning  the patient's phone calls in a timely manner). I make my written consultation available to both the patient and the treating psychiatrist. I am also available to discuss the case with the current psychiatrist. But, I will not take the dissatisfied patient in transfer.  This is really no less than I would hope if one of my patients has been dissatisfied with our treatment and calls another psychiatrist  to jump ship and short-circuit the process of working it out with me.  I would hope  the colleague would respond in kind to what I have described.  Sometimes, that is been the case, but sadly other times it has not. Just like, sadly, sometimes my patients go to the ER and are hospitalized and  the treating docs there never call me.

I know another psychiatrist who once mentioned that he wouldn't take on patients who are already in treatment with another psychiatrist.  I didn't ask why, I just assumed he didn't like the idea of taking someone else's patient, that perhaps he thought it made for poor professional relationships.  

As you can tell from the title of this blog post, I don't agree.  I think if there are times when treatment comes to an impasse, and it just gets stuck.  I think there may be transferential issues to work through, but that should be the patient's choice.  Sometimes people are less concerned with issues in the therapeutic relationship and are more focused on concerns that they aren't getting better.  Some psychiatrists are better than others in general, and some psychiatrists are better than others with specific patients.  And psychiatrists offer different services: I've heard from many people who've tried med-check only treatment who come looking for psychotherapy as well how, "That fifteen minute thing doesn't work for me."  I'm also not so sure that because a consultant recommends that the treating physician should return phone calls in a more timely manner that it necessarily happens. 

Finally, the psychiatrist assumes that when the going gets tough, the psychiatrist wants to continue.  If a patient isn't getting better, or if therapy has become a war zone, then sometimes everyone agrees that it would be best for a fresh start.  Also, do remember that this is one psychiatrist's personal policy for his own private practice, and certainly, I believe doctors should practice in ways they find ethical and comfortable.  No one has actually suggested a true Hotel California policy where "You can check out any time you like, but you can never leave" and patients can never change psychiatrists.

At the other extreme, Roy once told me that if ever returned to private practice he would see patients for only one year: by that point they should be better or they should try treatment with someone else.  

I think patients should be able to change doctors -- of any flavor-- if they aren't happy with the care they are receiving. I didn't post this to poke holes: the psychiatrist above makes some very good points, and he does a nice job of putting into words what others may not verbalize as well.  His comments gave me the opportunity to think about this, so I wanted to give our readers the chance to ponder and discuss as well.  Note that comment moderation is off, so please do be kind to one another. 

Interview with Touched With Fire Director Paul Dalio

A few weeks ago, I wrote about a screening I went to for the film Touched With Fire. 

 Last week, I had the chance to interview the film's director, Paul Dalio.  My article about the interview is over on Clinical Psychiatry News, so please click over there to read about this remarkable man and his new movie.  bit.ly/1SkleFU

Guest Blogger Dr. Mark Komrad on Evidence-Based Medicine and Clinician Experience

In my last post- Medications, Parrots, and Crazy Virginia Laws --, I talked about Robert Whitaker's post on Pete Earley's page.  I put a link to Pete Earley's blog, but not my Shrink Rap post, up on my personal Facebook page.  Now some of my Facebook friends are psychiatrists, so this turned my Facebook page into something of a blog post, with no cute animals.  You followed all that, right? (It's some weird version of social media hell, and yes, I tweeted it as well).  The commenters there gave me permission to put their responses as comments on Shrink Rap, but Dr. Mark Komrad's response exceeded the character count for a blog comment, so I'm giving him a guest post slot here.  Dr. Komrad is the author of You Need Help! an excellent book on how to get a loved one into treatment. His response is below:
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I think  there are some emerging intellectual "cults" or "fetishes,” maybe best called "overvalued ideas,” that are relevant to Whitaker’s blog post.   A major one now dominant in Medicine is “evidence based."  Not a bad concept, but an overvalued one.   My experience as a practicing clinician so often contradicts the evidence base. Can this just come down to the dismissal of the clinical experience of a seasoned clinician as invalid because of individual-bias? Should the wisdom of clinical experience be trumped (wow- a word whose meaning is changing!) by large statistical sets, or amalgamated statistical sets, as in meta-analyses? That seems very much black-and-white thinking. There is a dialectic between two different ways of knowing-- clinical experience vs. the study of large sets of patients under controlled conditions. We in psychiatry are familiar with many such dialectics: mind and brain, nature and nurture, biology and psychology, form and content, autonomy and paternalism, explanation and understanding, etc. See Philip Slavney, "Psychiatric Polarities."

In my own experience, I practice not too much differently from many other psychiatrists, and not radically different from what Whitaker wants. In schizophrenia, I follow "first break" research and go "low and slow." Early in the course I attempt to taper off antipsychotics slowly. That commonly fails, but not always. With long-term patients I have tried time and again to lower doses to the lowest possible dose. I make tiny changes over many months or even several years (yeah, I've been around long enough, and my patients stay with me)-- slow enough to rule out withdrawal effects. Yet time and again people end up eventually relapsing,  and we have to reverse course. With the majority of patients, reversing course doesn't work, and a few have never returned to their former (often excellent) baseline (prior to trying this oh-so-cautious tapering). For many patients on maintenance meds, the dose goes up, the dose goes down, as symptoms wax and wane-- like any other chronic illness. Make no mistake, schizophrenia IS a chronic, lifetime illness, and the chronicity is not CAUSED by meds, as ample evidence suggests, from the pre-antipsychotic era. It seems very compelling to me, from my 30 years of clinical experience in treating schizophrenia, that these meds don't only have acute efficacy (like antibiotics), but also prophylactic value, to minimize morbidity (like Lipitor). 

Of course, I cannot rule out the possibility that, as Whitaker suggests, long-term antipsychotic treatment might partially  cause the brittleness and dependency on meds for stability and remission. That could account for my frequent experience of failed-tapers. It's a good question for research. But it would take a few decades to be sure, by following parallel cohorts of persistently medicated patients and rarely medicated patients. Maybe enough time has passed in the antipsychotic era that some valuable evidence is now just emerging. But 4-5 year studies wouldn't be enough time. It would need to be 20-30 years. Those are quite difficult (and expensive) studies to do. I remember how expensive and complex it was to do the multi-center study 20 years ago that asked about maintenance meds in recurrent depression after patients get well-- can you stop, lower the dose, or should you sustain the same dose it took to achieve remission? (answer: the third). Many millions $,  20 centers, and that was only 5 years. 

I have shared the ambiguity of treatment choices, based on some of these studies, with some of my patients and families. It is, however, RARE that a patient who is doing well wants to take a chance. The overwhelming response has been, "if it's not broken, don't fix it." In patients that are doing well, with the current state of evidence, it's hard to ethically justify tapering them off antipsychotics entirely. Even patients doing poorly have done WORSE when meds are stopped. Maybe, EVENTUALLY they might do better, these studies suggest, but until then, their increased morbidity off meds, even temporarily (months, years), will be extremely bad for their lives, the lives of others, and even their very survival. 

Maybe 25 years from now there will be enough evidence and new EXPERIENCE by clinicians who have started early in the onset of schizophrenia to use more temporary courses of antipsychotics. Then, maybe clinical experience will corroborate some of these very preliminary studies. That might enable the power of more statistical studies to be complemented by the equally valuable power of clinical experience. As is typical, in the evolution of Medicine, the dialectic of these two ways of knowing will result in the synthesis of changing treatment approaches. By then, though, we may have entirely new and different inventions for treating schizophrenia!

Medications, Parrots, and Crazy Virginia Laws

For today's post, I'd like to send you around the web.

First, Pete Earley has a piece up by Robert Whitaker of Mad in America. Whitaker clarifies his position on antipsychotic medications and how their use should be avoided or minimized  in Robert Whitaker Explains his Research after being Pigeon-holed as Anti-Medication.  Let me add my bias: I didn't like Whitaker's book Anatomy of an Epidemic where he concluded that anti-psychotics cause psychiatric disability.  His point was correlational -- as anti-psychotic use went up, so did SSDI (government disability) claims. It's not that easy -- there are other factors that contribute to disability claims including financial & social incentives and the acceptability of being on SSDI.  After you read the post on Pete's blog, I'd like to make two points:

~I don't think that it's controversial that people should be on the lowest possible dose of medications --any medications.  Unfortunately, in psychiatry, we figure out the lowest dose by dropping the medications until someone gets sick.  It's not benign, with each small drop in dose there is some risk that a person will end up psychotic, in the hospital, or unable to function, and recovery can take months or more.  So when someone is doing well, working and involved in meaningful relationships, it's not a low risk issue to drop medications.  If they are having side effects, it's a lot easier to take this risk, because at least you're addressing a problem.  This stuff is not easy when you're talking about real people.

~I remember life before the second generation antipsychotics.  Patients hated taking Haldol and Prolixin and Mellaril and Stelazine.  They were very articulate about how miserable the side effects were, and I don't recall anyone saying that patients wouldn't take Haldol because they had "anosognosia" (ah, we didn't have that word then).  Psychiatrists were well aware that patients didn't take the medications because they made them feel like molasses had been poured into the crevices of their brains, or worse.  Second generation antipsychotics may be no more effective, but they are more acceptable to many patients.

Having said all that, Whitaker may be right that people do better with less medicine, either because those who aren't as sick don't need as much medicine and may be able to completely stop, or because the medications sensitize people and make them worse (I have no answers here.)  When someone is psychotic and suffering, this isn't all that helpful.  I wish we had better answers. Whitaker, and others point to Open Dialogue as a panacea, and it may be a better way with better results -- not much of it is controversial, just expensive and it requires resources for immediate response that we don't seem to have in this country.  There are 5.5 million people in Finland and 321 million people in the US, so the issues are different, and people in Finland get hospitalized and disabled, too. 

While I'm pointing you around, Alex Langford does a nice job of discussing Open Dialogue with all it's pros and cons on his blog Here.  Well worth the read. 
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You've heard of Creigh Deeds? He's a Virginia state senator whose very ill and very dangerous son was released from an ER because of a quirk of Virginia state law that said if a bed could not be found within 6 hours, then a patient must be released.  Tragedy ensued -- Gus Deeds repeatedly stabbed his father and then died of suicide.   Over on Clinical Psychiatry News, I explain the idiosyncrasies of Virginia law that could allow such horrors to happen.  See Understanding the Deeds Family Tragedy.

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And for the latest news in schizophrenia research, here's a study in Nature that's making headlines everywhere.  If I could understand it, I'd explain it to you.  Maybe Roy could drop by for this one? We haven't seen him for a bit.
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Lastly, I'll include a link to an article about PTSD and parrots.  ClinkShrink likes birds, and she loves parrot jokes, so please do share yours.  What Does a Parrot Know About PTSD?
 

 

No, You Don't Need Psychotherapy

Dr. Michael I. Bennett had a opinionator piece in the New York Times a few days ago that made my blood boil.  In You Are Stronger Than You (And Your Therapist) Think,  Bennett talks about a patient who has been in weekly psychotherapy for years until the insurance company decides that the patient does not need weekly sessions -- 12 sessions per year are approved.  But the patient is not Bennett's patient, and he writes from the perspective of someone who has worked for an insurance companies. 

Bennett writes:

I know what it’s like, as a psychiatrist, to feel that your patient’s safety depends on your availability to provide emotional support. However, I also know from experience that patients usually survive our vacations, unavoidable short-notice absences and cellphone failures without actually falling apart. Certain patients feel very vulnerable, needy and worried about abandonment, but they feel that way long before we start treatment and, usually, those feelings don’t change in response to treatment. Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be, or as we experience it to be.

If weekly therapy does, indeed, have only a limited potential to heal and protect, then our patients must be stronger than they, and we, think they are. We know that depression and anxiety routinely distort our ability to think realistically by making us see nothing but our faults, failures and worst-case scenarios. When we’re sure that things will fall apart if weekly treatment isn’t readily available, we may well be accepting and stoking this distortion and, inadvertently, helping our patients believe that they are as weak and helpless as they feel.

Depression and anxiety, Bennett explains, can make some people feel like they can never be strong.  He goes on to advice:

My advice to my colleague was to make a list of the patient’s strengths and encourage her to review what she had learned from the tough experiences that she had endured and survived. It would be normal for her to fear the worst from the coming transition in treatment, but this was also an opportunity for her to see through the negative distortion caused by that fear, review her resources and prepare plans for managing whatever worst case scenarios she could imagine. My colleague could assure her, of course, that emergency care was available. But he could also express confidence in her ability to use what she had learned in their work together to survive and thrive, in spite of her doubts and fears — and of his.  

Where, oh where, to begin.  To contain my urge to rant and ramble, I'll hold my analysis to a few bullet points:

• Obviously, Bennett may be right that therapy may foster dependence.  The therapist may be financially motivated to patients coming frequently, and there are patients who could be seen less often then they are.
• So how do we determine how often a patient should come?  The therapist & patient in this case say weekly; the insurance company says monthly.  Why 12 appointments?  Why not 11 or 13? Or 17? Or 9?
• What is the goal here? Is it to find that absolute minimum number of appointments that the patient can tolerate without another serious suicide attempt (as this patient had)?  Without hospitalization?  With medication? Without a recurrence of symptoms? (Which Symptoms?)
• Is dependence bad?  What if one hour a week of "dependence" and any accidental psychotherapeutic work that happens to happen along with that dependence comes with the the trade-off is able to live life more fully and productively?  
• "Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be, or as we experience it to be."  Excuse me??? Oddly enough, it seems to me that the therapeutic relationship is often quite helpful.  
• Might I add that very few patients continue for an extended period in weekly psychotherapy -- it's expensive (even with insurance there are deductibles and co-pays), and time consuming.  There is some automatic self-selection here that leaves the most vulnerable and distressed of people who even want this.
• Okay, so what do we think about someone from an insurance company who has never met a patient, and generally hasn't reviewed their history and medical record,  should determine how much treatment they need?  Oh wait, managed care has been around for a while.  Now whose idea was that?

Your thoughts?
 

Drowning Bunnies

There was an interesting article in the Washington Post today about a new college president, brought in from the private sector to help a college flourish, who spoke on increasing retention/graduation rates.  In an article provocatively titled "University President Allegedly Say Struggling Freshman are Bunnies that Should be Drowned" (okay, it got my attention), Susan Svruiga writes:

Amid a conversation about student retention this fall, the president of Mount St. Mary’s University told some professors that they need to stop thinking of freshmen as “cuddly bunnies,” and said: “You just have to drown the bunnies … put a Glock to their heads.”

Simon Newman was quoted in the campus newspaper, The Mountain Echo, on Tuesday, in a special edition that reported the university’s president had pushed a plan to improve retention rates by dismissing 20 to 25 freshmen judged unlikely to succeed early in the academic year. Removing students who are more likely to drop out could hypothetically lead to an improvement in a school’s federal retention data; the deadline for submitting enrollment data is in late September.

Newman, a private-equity chief executive officer and entrepreneur who was appointed president of the private university in Emmitsburg, Md., in 2015, said Tuesday that there are some accurate facts in the Echo story, but “the overall tone of the thing is highly inaccurate.”

Oy.  I don't know what President Newman's issue is that he talks about drowning and shooting bunnies, but I since I don't know him --and would like to keep it that way-- I'm going to refrain from commenting on the judgment of the president of a religious educational institution who uses such harsh, violent, and vivid metaphors for talking about those he's entrusted to educate.  

So I'm not sure this is a psychiatric issue,  but I want to comment on the wisdom of weeding out freshmen who are doing poorly in their first month of college.  If one could tell within weeks of their arrival on campus who is definitely not going to make it to graduation, then I would agree with Dr. Newman's concept, but let me use my own language.  If you know for sure that someone is not going to be able to graduate from college, then you would do them the kindest service by not accepting them into your university to begin with.  If you did make a mistake and accept someone who obviously cannot succeed, then it may be best to help them exit early.  College is not for everyone, and if you're never going to graduate, then it may be better to forgo the expense, the debt, the years of struggle and discouragement, the lost income and lost opportunities to master other skills.  Of course, this could be wrong; someone who never graduates may learn incredibly useful things -- both in classes and in the struggle-- and may form invaluable friendships and networks.  Bill Gates didn't graduate from Harvard. Steve Jobs dropped out of Reed.  They did okay without the sheepskin.

Even if it's not all about the diploma, the fact is that the first semester of college is a very stressful time.  Teenagers are leaving home for the first time, they have to wake up and get to class without alarm-clock Mom, perhaps after late nights up using their newfound freedom to discover substances or the opposite sex.  They may not have a sense of how much they need to study, and some may be up far too late pounding at the books, or simply worrying.  Others have to work to get all the bills paid, and figuring out the work/college/social aspects of school may be quite hard.  Some college freshmen get homesick.  Some become ill with serious psychiatric disorders.  But even the smartest, healthiest, and most driven of students may struggle that first semester in college.  Since college is about educating people, it does seem that some tolerance of these difficulties is needed.  From what I can tell,  the predictive value of that first semester is not terribly good.  I've heard stories of kids who've had any number of  issues and terrible grades, who have then gone on to do well.  It may not have been a smooth ride, but it was one that got finished.  

I vote for coddling the bunnies for a while, at least while they get through the transition of separating from their families and figuring out their new environments and its demands.   And you know, I don't think glocks are the answer to very much, and I'm all for a kinder, gentler world.    

Why Can't We Get Help?

On January 8th, Bloomberg Business ran an article on how law students are reluctant to get treatment for psychiatric problems and for addictions. It's not that law students don't suffer from these problems; in fact, surveys show they do in significant and increasing numbers.  Natalie Kitro writes:

People preferred to leave their illnesses untreated than risk not becoming a lawyer. More than 60 percent of students said they didn’t get help for their reliance on drugs or alcohol because they were worried it would affect their career prospects or their chances of getting admitted to the bar. Before they can practice law, students have to pass a “character and fitness” screening, in which officials look into their personal histories with the aim of rooting out people who are too morally compromised to serve clients. The American Bar Association says potential red flags include “drug or alcohol dependency” and “mental or emotional instability.”

Law schools have tried in recent years to convey that students will not be penalized for admitting that they’re suffering, but the report suggested that the efforts haven’t gone far enough. It is tough to counter what the study characterized as a deeply rooted culture of fear in legal education that discourages students from admitting weakness. 

So much for our legal colleagues.  Today,  Dr. Aaron Carroll has a compelling article in the New York Times about why doctors don't get help for psychiatric disorders. "In silence is the enemy for doctors who have depression," Carroll courageously starts by talking about his own episode of illness.  Carroll notes:

Last month, a study in the Journal of the American Medical Association reviewed all of the literature on depression and depressive symptoms in resident physicians — those are doctors still being trained. They found more than 50 studies on the subject. Research shows that almost 30 percent of resident physicians have either symptoms or a diagnosis of depression.

He goes on to postulate:

What makes this all worse is that medicine is a profession in which admitting a problem carries a stigma that can have more impact than in others. A study published in 2008 surveyed physicians in Michigan, asking them about their work experiences and if they had depressive symptoms. More than 11 percent reported moderate to severe depression. About a quarter of them reported knowing a doctor whose professional standing had been hurt by being depressed.

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Credit Jody Barton

Physicians with moderate to severe depression had a decrease in work productivity and job satisfaction. They were also two to three times more likely to say that they were worried about, or had difficulty getting, mental health care. Although the Americans With Disabilities Act, passed in 1990, prohibits employers from asking broad questions about illnesses when people apply for jobs, state medical licensing boards still ask specific questions about mental health.

Because of this, physicians are much more likely to avoid treatment. They’re also more likely to self-medicate.

Sometimes that medication is appropriate, as with anti-depressants. Often, it is not. A 2012 study in JAMA Surgery found that more than 15 percent of the members of the American College of Surgeons had a score on a screening test consistent with alcohol abuse or dependence. Among female surgeons, the prevalence was more than 25 percent. Those who were depressed were significantly more likely to abuse or be dependent on alcohol.

And if that's not enough, two weeks ago, KevinMD ran an article called "Don't poop wher you eat: Mental Health Services for Young Physicians".  Amy Ho talked about insurance requirements that residents in training often must get health care --including mental health care -- at the institutions where they work.   Ho talks about the 29% of residents who are depressed, and the reality of seeking mental health care at an institution where you work:

While privacy protection acts like HIPAA are real, they are difficult to trust when you know every single one of your co-workers and ancillary staff (nurses, attendings, etc.) have a password into your private file. Further, unrelated medical care (for example, an ER visit during work hours from a needle-stick accident) allows completely HIPAA-compliant access by one of your coworkers into all of your records.

There is a saying, “Don’t [poop] where you eat” — that is, to keep personal and professional separate. For many residents whose health care is limited only to their place of work, there are often no other options. Of depressed first-year residents, over half cited “perceived lack of confidentiality” as a barrier to treatment.

So I'd like to suggest that these issues of stigma have gotten worse, and not better.  When I was a medical student at an institution with a strong psychoanalytic bent, entering psychotherapy was considered part of what one did to get to know yourself better: essential if you were going to be a psychiatrist, but also not shameful if you believed the unexamined life was not worth living.  People talked openly about being in therapy.  The chief resident in psychiatry put his analysis schedule on the unit bulletin board (times not to disturb him).  A cardiologist told me he wanted to be a psychiatrist until he went into treatment and realized he only wanted to deal with his own issues.  People openly talked about going to therapy.   One of my classmates had a very serious suicide attempts -- it wasn't widely known, but I asked her roommate where she was headed one evening and the answer was to visit her in the ICU where she was on a ventilator.  I don't know what transpired from there, but I do know she wasn't kicked out of medical school--as she might have been today-- and she went on to graduate on time and to obtain a very competitive residency slot. It's not that it was such an ideal world -- many people at my undergraduate school died of suicide and I don't know if those people were in treatment or not. But in some circles, there was less concern with secrecy and stigma.

I believe that certain behaviors have always been, and always will be, stigmatized.  When your mental illness leaves you to suffer quietly, the problem is yours, and if we hadn't come to associate "mental illness" with mass murder, and the possibility of unpredictable, disruptive behaviors, if we didn't erode privacy with records in the cloud, and if we didn't make it so damn difficult and expensive to get good treatment,  then there should be no shame for seeking treatment for depression, anxiety, or even most substance abuse problems.  I'm not sure our society has ever been comfortable around florid psychosis, nor do I think it ever will be.

Okay, hold with me for one more article.  In yesterday's Washington Post there was the story of the Dallas District Attorney who's position was being threatened because she disappeared for a couple of months to get inpatient treatment for depression, and had been treated for substance abuse.  But this DA's illness was, per the media, not just about her own personal suffering.  In a paranoid state, she fired  colleagues, she was obviously intoxicated at work, and her illness left her impaired and made life difficult for others, until she got treatment and recovered.  A judge dismissed a lawsuit to oust her. I wish her all the best moving forward.  One might hope, however, that people in such powerful positions might feel it's safe to get help before their problems effect others. 

Is Everyone Mentally Ill?

We talk about mental illness based upon a standardized set of symptoms, where the symptoms co-occur in groups/clusters/syndromes in ways that enable us to cluster them together (i.e. make a diagnosis), treat the illness we've defined, and have some means of predicting outcome (i.e. 90% of people will have full remission of their symptoms within 6 months).  We talk about these clusters of symptoms as being illnesses or disorders, and we look for biological correlates -- changes in brain chemistry, anatomy, metabolism -- to divide those people who have the disorder from those who don't in the hopes that someday we will have tests to tell us who will respond to various treatments.  It would be very nice to get rid of all this trial and error medication cocktail stuff and just have a test that says "Meds won't work for you, you need TMS," or "no point in using an second generation antipsychotic, go straight to clozapine."  So far, no great breakthroughs in terms of either diagnosis or treatment predictability, but give it time. 

So there was an article in the New York Times on January 2nd titled "Is the Drive for Success Making Our Children Sick?" Vicki Abeles talks about how childhood stresses lead to illnesses, including ulcers, as well as more medical illnesses as children age into adults.

Abeles writes:

STUART SLAVIN, a pediatrician and professor at the St. Louis University School of Medicine, knows something about the impact of stress. After uncovering alarming rates of anxiety and depression among his medical students, Dr. Slavin and his colleagues remade the program: implementing pass/fail grading in introductory classes, instituting a half-day off every other week, and creating small learning groups to strengthen connections among students. Over the course of six years, the students’ rates of depression and anxiety dropped considerably.

But even Dr. Slavin seemed unprepared for the results of testing he did in cooperation with Irvington High School in Fremont, Calif., a once-working-class city that is increasingly in Silicon Valley’s orbit. He had anonymously surveyed two-thirds of Irvington’s 2,100 students last spring, using two standard measures, the Center for Epidemiologic Studies Depression Scale and the State-Trait Anxiety Inventory. The results were stunning: 54 percent of students showed moderate to severe symptoms of depression. More alarming, 80 percent suffered moderate to severe symptoms of anxiety.

“This is so far beyond what you would typically see in an adolescent population,” he told the school’s faculty at a meeting just before the fall semester began. “It’s unprecedented.” Worse, those alarming figures were probably an underestimation; some students had missed the survey while taking Advanced Placement exams.

Okay, so wait, at least half of a group of students surveyed were moderately to severely depressed (?what about mildly depressed), and 80% were moderately to severely anxious?  And the symtptoms abated when the stress disappeared?  This doesn't make sense -- are our disorders illnesses --- brain diseases (as some like to call them)-- or are they part of the spectrum of normal reactions to stress, pressure, and likely lack of sleep? 

In a clinical setting, I'll tell you that sometimes it feels really clear cut: there are people who get sick and they get severely psychotic, or they markedly change from their usual personality. They shut down and lose their usual vitality and ability to function; they aren't showing up for those AP exams.  They become so symptomatic that they become someone totally different, and there is no 'hiding' their illness.  In other cases, it's not so clear cut -- people come in complaining of symptoms of depression, loss of interest, sleep changes, libido changes, suicidal thoughts, and any mix of symptoms that meet criteria for a disorder, and they attribute their distress to a given set of life circumstances.  But they're functioning in their usual roles,  and they are able to mask their symptoms: the rest of the world may not know how badly they feel.  If they are coming to see me as a psychiatrist, they often want medications, and medications often help.  Would they need medications if we could remove the stress?  Often they say 'yes' but we can't make that happen.  Maybe you're thinking about school stress and pressure to achieve, but there are other stresses -- illnesses, financial burdens, divorce, family chaos -- which don't go away by dropping a class or giving up tuba. 

If the studies cited above are accurate -- and I didn't look at them -- and the symptoms are persistent, then this doesn't fit with our idea of mental illness.  It comes to be about a normal reaction to stress, a need -- as noted above-- to change our environment, and a question as to what gives resilience to those few who don't have symptoms.