Monday, December 04, 2017

Recent Reads: Black Man in a White Coat and Vengeance



I just wanted to put up a quick note about two books I've read recently.


Black Man in a White Coat is a memoir written by Duke psychiatrist Damon Tweedy.    So what's it like to be a black med student and doctor, and not just anywhere, but at Duke.  Tweedy notes that he was accepted at other top medical schools, but that he went to Duke because the only way they could attract African American students was by giving large scholarships.  That gives you a hint as to what the environment was like.  So it's not surprising to read that Tweedy was standing with a classmate, purposefully dressed in a polo shirt and khaki's, only to have the professor walk into the lecture hall and ask if he was there to fix the lights.  Ugh.  So not specific to psychiatry, but a good read with important insights into how racial issues play out in medicine.  




Moving on to fiction, you may remember Pete Earley from Crazy: A Father's Search Through American's Mental Health Madness.  Pete is a mental health advocate, but at night, he steps into a phone booth (remember those?) and steps out dressed as a novelist.  Paired with Newt Gingrich, this fabulous novelist duo has now written 3 books in a series: Duplicity, Treason, and now Vengeance.    They follow Major Brooke Grant as she travels around the world chasing the Falcon, a dangerous terrorist who ultimately knocks off everyone Brooke loves (or almost).  Vengeance is by far the best of the three books, and I don't want to say too much, because it's a better read without the plot spoilers.    

Monday, November 27, 2017

Happy Holidays from Shrink Rap: Free Kindle Novel Promotion!


Happy Holidays!

At this time of year, I like to set up free downloads to two of my novels. You can get these books for free on your Kindle from Tuesday, November 28th through Saturday, December 2nd at no cost.

Double Billing is the story of a woman whose life changes when she discovers she has an identical twin. It's a quick read with a little  psychiatry sprinkled in.  One reviewer said:

 The book was a page-turner because of elegant structure and pacing.  I really cared about the author’s take on things –because she is a psychiatrist? because I’ve followed  her blog for a while?– which meant that I was interested in the protagonist’s thoughts, feelings and actions.  At times I ached for the mess her life was in, at others I wanted to shake her into action, and then she’d find her backbone again, just in the nick.  



Home Inspection is a story told through psychotherapy sessions in a format that is similar to the HBO series In Treatment. Dr. Julius Strand is a psychiatrist who plods along in his already-lived life until two of his patients inspire him through their own struggles to find meaning.  One reviewer wrote:

 I like to read all sorts of books, but books where there's something in it that reflects a part of me, a part of my life, a part of my experiences, are something I go out of my way to find. I have not found any fiction book that does nearly as much to show what psychotherapy is like.

There is is a single link to my Amazon page with all my books here.
 

If you don't own a Kindle reader, you can install a free Kindle app on your computer, tablet, or cell phone by going here and then you can read any Kindle book. You don't need to buy a Kindle to read on your computer, tablet, or smartphone.

 Both novels are also available as as paperbacks from Amazon, but not for free.  And our two non-fiction books can also be found on that page, but again, not for free.

I'm more than happy to have people download my novels at no cost
-- I'll be keeping the doctor day gig -- so please tell/tweet/blog/share the free promotions to anyone you think might be interested.

Finally, If you do read any of the books, please consider putting a review on Amazon.   

 

Monday, November 20, 2017

Laura's Law (outpatient commitment): The Answer to Preventing Mass Murder?


2017 has broken the record for the most mass murders in a single year -- not something to be proud of, my fellow Americans.

After the latest mass shooting in Tehama, California, John Snook, the executive director of the Treatment Advocacy Center had an op ed piece in the The Sacramento Bee titled
"Tehama Country had a tool to Get the Shooter Into Treatment.  It Just Didn't Use it and the System Failed."  The article notes that Laura's Law, where a judge orders a patient to get outpatient treatment, exists in many California counties, but not the one where the shooter lived.  If only, if only.


We know little about this shooter.  He was a violent man with a history of stabbing a woman (he was out on bail) and of shooting at neighbors.  His sister has stated that he had a long mental health and he was paranoid, and anti-government.  Prior to his shooting spree, he killed his wife and buried her in the floors.   The shooter worked as a marijuana farmer, we know nothing about his drug use or his treatment history.  He was known to the police, and clearly repeatedly dangerous, but the judicial system saw fit to let him remain out of jail on bail, which his mother in North Carolina posted, while he awaited trial. His guns were made by the shooter with pieces he had ordered and assembled, other guns were registered to someone else (?stolen).  He had a history of violence, and this crime does not sound to have been a surprise to the neighbors who feared him; one of the victims was the woman he had previously stabbed.

So would this mass shooting have been prevented if Laura's Law was implemented in his country?
First off, we don't know about the shooter's mental health history.  Oddly enough, while Tehama does not have outpatient commitment, the shooter could have been confined on an inpatient unit if a "5150" had been filed to detain him for an evaluation on an inpatient   Also, the shooter had multiple charges for violent crimes -- he could have been diverted to a mental health court and mandated into treatment through the legal system.  That also didn't happen-- or at least we haven't heard about any of those actions happening.  I suspect that the shooter fell through the mental health system  cracks, but it's clear he fell through the cracks in the legal system.  

So would Laura's Law have prevented THIS mass shooting?  Perhaps, if the following list of stimpulations were met:
~If the shooter's violence was a product of his mental illness.  People without mental illness are violent, and people with mental illness are violent for reasons unrelated to their psychiatric disorders.
~If the shooter's symptoms that caused him to kill people were eliminated by the use of psychiatric medications.  Not everyone has a good response to medications and so far, we haven't heard that he was so much better when he took medications.   Forcing people to take medications doesn't fix/prevent everything, and the average length of stay in a forensic facility for people who have committed violent crimes due to their mental disorders is YEARS.  Sick, violent people don't magically get better with a judge's order. 
~If the perpetrator was ordered to treatment and if he complied with the order to go to treatment and to take medications.  Not everyone does, and from what we know, this man broke laws, both with his violent behaviors, and with his planned and purposeful assembly of illegal weapons.
~If services were available for the perpetrator to receive them. In half the counties in this country, there are no mental health professionals.
~Does Assisted Outpatient Treatment prevent gun violence?  We don't know.  In New York, where AOT has been studied, one large study showed AOT, with partner services including case management and housing prioritization, AOT reduced hospitalizations and incarcerations, but people with a history of violence were  excluded from the AOT study.  We don't know that outpatient commitment reduces violence or gun violence.

Just a thought: other countries have mental illness illness.   Other countries don't have mass shootings.  What else they don't have?  One gun for every citizen. 


Tuesday, November 14, 2017

When Paranoia Meets Reality: Your Medicine Snitching On You



Medication non-compliance is a problem: patients don't take their pills.  We hear about it all the time in psychiatry: people don't take their medications and they relapse.  Sometimes they decide they don't need them when they do, sometimes they don't like the side effects or risks of the medications, but mostly, they just forget.  You may hear about this problem as if it belongs to psychiatry, but it doesn't.  Patients don't take their cardiac medications, either; in fact humans are only randomly compliant with all types of meds.

Swoop in technology, here to solve the problem.  Now sensors placed in tablets can notify the doctor and up to four other people to inform them if and when a patient has taken their pill!  And what pill was was the first to be approved for the use?  Abilify: an anti-psychotic medication used to treat schizophrenia and bipolar disorder, and also used to augment anti-depressants.  Was that the wisest choice?  To have a tattle-tale system in a medication used to treat paranoia?  I'm thinking there could be a better place to start.

So the patient swallows a medication and his stomach acid signals the sensor.  He also has to wear a skin patch on his abdomen, under his ribs.  A notice goes out to an App on his doctor's phone, and to anyone else he wants notified (presumably himself).  He has to consent to this, but questions have been raised about whether the courts will require patients to do this in terms of release from incarceration, for mental health courts, or if it will be priced in such a way to incentivize it's use.  Will people be coerced?  Will they like it?  Will they remember to check their App to see if their loved one took their medication?  Do doctors really want to be notified every time a patient takes their medications?  Will EMRs now have boxes to check to verify that the doctor has looked to see if the patient has swallowed his pill, as directed, daily, at the correct times? Will doctors be liable if they fail to check results and take action when patients aren't taking their medications and if there is a bad outcome? Will sensors work to improve medication adherence?  And then there is the Creepiness Factor.   You can tell I'm a bit skeptical of this, but that's not new.  ClinkShrink will happily tell you that I was wary of the Internet the first time I went surfing: too slow, it will never catch on.  I was wrong. 

Want to read more? Here's the New York Times article: First Digital Pill Approved to Worried About Biomedical Big Brother.

Your thoughts?

Thursday, October 12, 2017

Let's Talk About Jails and Mental Health


Really, this is a post for ClinkShrink, but she's been busy with other things.  Do you miss her? Let me invite you to listen to Clink's interview on Tier Talk/Corrections One, where she was interviewed about Are Prisons Turning Into Mental Health Hospitals? 

Yesterday, I heard Dominic Sisti talk at Sheppard Pratt Hospital about mental health and incarceration: Dr. Sisti is the director of the Scattergood program for the Applied Ethics of Behavioral Health Care at the University of Pennsylvania, where I was an undergraduate just a few (hmmm) years ago.  I tweeted the lecture, as best as I could, along with photos of some of the slides, so do check out the hodgepodge of venting that is my twitter feed.  

I want to use this opportunity to talk a little about the highly publicized statistics that many many people in jails and prisons are suffering from mental illness.  Many believe that correctional facilities are the new psychiatric facilities.  Why is this?
~Dr. Sisti and the Treatment Advocacy Center, and many others, will contend that part of the issue is that state hospitals have closed their beds without providing for adequate community services, so this represents a "transfer" of people from one institution to another. 
I will add:
~Many people have psychiatric problems -- per NAMI, 1 in 5 in any given year --so we certainly would expect some people in jails and prisons to have mental disorders.
~Mental illness often co-occurs with substance abuse, and substance abuse is a crime in our country.
~Mental illness causes people to be poor, and poor people are more likely to be in correctional facilities, because poverty may lead to crime (eg. stealing food), and poor people can't afford bail or expense defense attorneys so they may stay in jails longer than people with financial resources.
~Our country has the world's highest incarceration rate, and we imprison people we are mad out, not just those we are afraid of.  There has to be a better option than imprisoning people for nuisance/non-violent crimes.  Many, many people go to jail for "violation of probation" when they can't meet the conditions set by judges -- for many of these folks, showing up is something they just don't seem to be able to negotiate.  For some, there is home monitoring, for others there is weekend jail, but there are many people in our jails where incarcerating them amounts to our society cutting off it's nose to spite it's face: a legal record makes it harder to find employment and the cycle of crime continues.
~Incarceration rates have gone up with the "War on Drugs," minimum mandatory sentencing requirements, and an increase in drugs and guns in our society in the decades following the closure of state hospitals.  

Sometimes people suffer from mental disorders, and the symptoms of their disorder directly leads them to commit crimes.  For example, a person who is delusional and believes someone is going to harm him, so he hurts that person in what he perceives to be an act of self-defense and has no appreciation that this is wrong.  Or maybe the logic isn't that clear, but the role of illness is, such as shooting a president to impress Jody Foster.

Sometimes people have symptoms of mental illness that lead them to commit crimes, but with a less obvious link to their illness.  For example, people with depression are often very irritable, so someone who is unusually irritable may lose their temper and get into a fight that they would not have if they were not ill.

As mentioned above, sometimes mental illness leads people to conditions that make them prone to certain crimes -- for example someone who is too sick and disorganized to maintain housing may be more likely to be arrested for loitering or trespassing than someone who owns a home. 

I mentioned co-morbid drug and alcohol addictions, and those lead people to illegal drug use, belligerent behavior while intoxicated, crimes to obtain money to obtain drugs, job and family loss and many circumstances that may lead to criminal behavior.  While many people in jails and prisons are mentally ill, many more have committed crimes related to drug use.

Sometimes people who have mental illness commit crimes for reasons that have nothing to do with their mental disorders.

If someone is obviously very ill and unable to appreciate that their crime was wrong, then many states have a way out of the corrections system: they can plead Not Guilty By Reason of Insanity and be sent for treatment rather than jail.   This doesn't always go smoothly, and I'll invite you to read a recent New York Times Magazine article: When 'Not Guilty' is a Life Sentence.  

Finally, mental health courts provide for diversion -- people who have been identified as having mental disorders can agree to treatment in order to mitigate their legal problems, and we discussed these courts in some detail in Committed.  There are a few caveats to mental health court: the person must admit to having committed the crime, and certain crimes are excluded.  When I was researching this chapter, I spend some time in the Baltimore City mental health court with Judge Jack Lesser.  While Judge Lesser noted that people were identified for the court, it just mattered that they suffered from a mental illness, there did not need to be a clear link from the illness to the crime.  

So what's the answer?  Dr. Sisti suggested that we should return to the days of asylums, in the true sense of the word: humane places to care for people who can not care for themselves.  See an article in The Atlantic: Should the U.S. Bring Back Asylums?    I will tell you that I agree with Sisti: there should be somewhere for people to be when they can't care for themselves.  I would add that I want housing for ALL people, not just those with mental illness: that we have people living on our streets is an enormous shame for our country and whenever I hear advocates talk about the homeless mentally ill, I want to groan. In fact I do groan: why don't we care about all homeless people? Why just those with mental illness?  But I would add that if we return to asylums, that these institutions must be voluntary, otherwise they simply become human warehouses without an exit and an alternative form of incarceration.  If people can be sent to these asylums against their will, society loses an incentive to work towards helping people survive in the least restrictive environment, it becomes much too easy to toss people in these places and throw away the key, and return to the abuses of the past.

So what is the answer?  I wish I knew.  I'm here today to tell you the problems, but I'll invite you to add your comments and suggestions.

Saturday, September 23, 2017

The Chronically Suicidal Patient and Stigma from Within the Mental Health System

There's an on-line psychiatrist discussion group where docs exchange information, ideas and resources.  As in all things on-line, it's sometime is invaluable, and it sometimes makes me shake my head.  Today, I was tagged in a post that discussed an article in Psychiatric Times called We Need to Talk About Stigma in the Mental Health System.  Louise Harvey writes about her hospitalizations in the UK.   Here is an excerpt so that you get the idea, and in the UK the term "sectioned" means involuntarily hospitalized.


Quickly it became clear that I was considered to be a histrionic, attention-seeking young woman whose problems amounted to an individual moral failing, and a refusal to take responsibility. I was not alone. There were other young women my age and we were all subject to the same invalidating experiences which served only to exacerbate our distress.
Our common presentation was self-destructive; we self-harmed and attempted to take our own lives, refusing to suffer silently once our despair had surfaced, the seasons of being able to keep our demons under lock and key well and truly over.

The common refrains we would hear from mental health nurses and doctors went like this: ‘just take responsibility;’ ‘there’s nothing wrong with you;’ ‘you are bed-blocking’ (even though they had sectioned many of us, including myself, and it wasn’t in our power to free up any bed); ‘stop playing games;’ and the worst of all, ‘no one believes you.’

Despite being considered a risk to myself, and lacking mental capacity, these judgements were accusations of mere misbehaviour and laden with mixed messages: ‘you are too ill to make your own decisions,’ and simultaneously, ‘you should stop being willfully disobedient.’ It must be noted that these comments were not levelled at the male patients on the ward, and were not reserved solely for younger patients.

This kind of treatment followed me for years until a desperate attempt to take my own life by jumping from a bridge startled others into taking me seriously. I wasn’t meant to survive. I felt that I was a lost cause and that my inability to just snap out of the madness was a personal failing.

I may not have died, but stigma within the system kills. It is far deadlier than any amount of stigma that one might face outside of the system because these are the professionals we are told to go to for help. Many of my friends who were treated as I was have since taken their own lives because their distress was not taken seriously.


This was my response to the group of psychiatrists, based on my experience as a clinical outpatient psychiatrist and upon the research I did for our book, Committed.  Just so you know, within minutes, another psychiatrist called me out as being wrong, so take it for what it's worth.   And remember, these issues of how to manage chronically suicidal people are very difficult for everyone: the patient, the family, and even the psychiatrist.
 -----
Thank you for tagging me. This is a wonderful article, it gives us an insight into the world of the patient. I think we've all been ingrained (as people, not psychiatrists--if those can be different) that if someone does something negative to get attention, then we should ignore it so as not to reinforce it, and people who get suicidal as a means of 'seeking attention' (a horrible thing...note sarcasm) are often dismissed, or punished-- and the inpatient unit here is often used for punishment. The label "borderline" turns into name calling/blaming, and not the acknowledgment of a personality gone awry and something that no one would ever want to have. Would you want to live a life where stress made you feel suicidal or where slicing your skin was the only thing you could find to alleviate psychic pain? Of course not, and yet we, too, often blame the patient. 

What the behavioral 'ignore it' doesn't include is the Skinnerian concept of an "extinction burst." If you ignore a behavior to get rid of it, the behavior escalates before it extinguishes and in these cases, you end up with a dead patient. I fully believe that if someone is asking for attention with suicidal threats/gestures, you give them attention, in a kind and caring way. And you point out to them what they are doing, how upsetting it is, and you suggest that if they need attention, they might try asking for it rather than upping the ante. I've been known to call family members and say "your family member needs some TLC, they are feeling suicidal and would really appreciate some of your time and attention." It's a much quicker phone call than looking for a bed, and so far this hasn't come back to bite me, fingers crossed, no one has ended up dead. And I have been known to talk suicidal borderline patients out of going to the hospital (although I do say, if you really think you are actually going to kill yourself, then do go to the ER!). 

Short term (few day) hospitalizations may help people to regroup and live through a rough moment alive and so it should be done if there is no alternative, but this is not the best setting for a person with a personality disorder, and if the wrong chemistry occurs on a unit, things may get worse. Also, people with borderline personality disorder generally have co-morbid mood disorders that should be treated aggressively. Many people who behave terribly stop doing so when their mood is better. More than you wanted, and you know, it's a hard group of people to work with, and I am not the best at it. No deaths, but often these patients leave my care, and sometimes to my relief.

Also, do see my article over on Clinical Psychiatry News called Suicide: A Surprisingly Ambivalent Topic

Tuesday, September 05, 2017

My Friends in High Places on the HHS's Interdepartmental Serious Mental Illness Coordinating Committee




Move over, there's a new federal mental health committee in town.  The department of Health and Human Services has formed the Interdepartmental Serious Mental Illness Coordinating Committee My friends Pete Earley and Elyn Saks are both on the committee, and Pete has been blogging about the committee for a couple of weeks now-- the good, the bad, the ranting, and the missed opportunities after the first day of meetings last week.  You'll be pleased to know that I didn't miss the opportunity to put in one of my concerns: I emailed Pete and Elyn to tell them how pre-authorization for medications is having a negative impact on the practice of medicine, and psychiatry in particular.  Nothing new, but it's a topic that every medical organization has been fighting for years and nothing ever gets done, so I thought I would ask that it be brought up again.  My thanks to Pete for including my concern on one of his blog posts

When people talk about serious mental illness (SMI), I always have the same reaction: What is it?  From what I can tell,  one gets the designation with a diagnosis: schizophrenia or bipolar disorder or severe depression.  Apparently it's not about illness chronicity or impairment, or spending time in institutions, or whether an illness responds to treatment.  I'm always at a loss: as I've said before, our diagnoses are not precise, prognoses can be wrong, and people can be very sick at one point in time and very well at others.  So while 1 in 8 adults are on SSRI's, 1 in 5 suffer from an episode of mental illness during the course of a year, and half of us will have an episode of mental illness during the course of a lifetime, these people with serious mental illness are quite few: 4.5 million Americans.  I wish these people wore signs so we knew who they were and could divide the resources appropriately. 

That said, the conversation about SMI often flows to the topic of involuntary treatment.  It goes along the lines of ...if only.  If only we could force sick people to get treatment then they wouldn't end up in jails and prisons.  If only we could force sick people to get treatment then they wouldn't be homeless, on the streets, committing violent crimes and mass murders.  If only.  If only it were that simple.  What gets missed is that addiction co-occurs with mental illness, and poverty confounds it all --so if only people were not raised in poverty, exposed to violence, and addicted to drugs and alcohol, then so many fewer people would be living on our streets, in our jails, and committing acts of violence.  If only. 

There is another problem with this kind of thinking.  It divides us into those who are FOR and those who are AGAINST forced care.  It leaves out the key factors of Access to Treatment and Engagement.  Not everyone who needs care can get it: we have a psychiatrist shortage in this country.  And not everyone who says No to treatment will continue to say No, but if they do say No and the response is to have guards brutally tackle them and inject them with sedating medications, then there is a good chance that future efforts at engagement may be met with resistance.  Sometimes, it helps to meet people on their own level, to get to know them, to let them become comfortable and trusting, and then some of these people who initially said No may become agreeable to getting care. 

The argument goes that those who refuse treatment have an inability to see they are sick, that this lack of insight it a symptom of the illness, and therefore it is a medical issue, not a civil rights issue.  I hesitate to use the term "anosognosia" because the word has become so politically loaded; those who use it believe that involuntary treatment is often the only option. I would contend that people who don't believe they are ill can often be engaged in treatment.  I'm not one for standing in someone's face and asking, "Do you know you have a mental illness?"  Instead,  people will often take medications because they feel better on them, because they are good patients who do what the doctor says, because a family member asks them to, or because while they may not think they are mentally ill, they do notice that life goes better if they swallow a pill everyday. 

Yes, I do know that there are some very sick people who are offered quality care and who just can't be engaged, and who would benefit from care that is not voluntary.  But it's not a clear pro-force/anti-force picture, and it's always better to work with a patient if you can.

So thank you to my friends in high places who are giving their time, energy, and efforts to helping our federal government figure out how to help people with serious mental disorders.  I look forward to reading more about your endeavors!

Tuesday, August 01, 2017

Inpatient Psychiatry: Not All Bad


I'm going to send you over to the Washington Post for an article that was published last week, written by Stanford psychiatry resident Dr. Nathanial Morris:  please check out 'Psych Wards' aren't what you think

Morris makes the point that the inpatient psychiatry units is portrayed something out of a horror show,  when really it is a place of healing.  He writes:

These are places where patients put their lives back together, picking up the pieces torn apart by such illnesses as depression, bipolar disorder and schizophrenia. Caregivers from doctors and nurses, to social workers and psychologists work to heal the sick, to guide patients out of the abyss. Families often reconcile with loved ones. Patients may find hope in one another, opening up in groups, sharing meals, discovering the comfort of shared experiences.

Morris is right. People go in to hospitals in miserable states and they come out better.  They don't, however, necessarily appreciate the care they've received.  As we note in our book, Committed, some people come out feeling terribly traumatized.  If they feel better, they may attribute it to reasons other than the psychiatric treatment they received.  Perhaps they healed from time, or being away from their problems,  or the kindness of a nurse or their fellow patients.   Ah, yes, moments of healing.

Morris points out that part of destigmatizing inpatient care involves acknowledging psychiatry's dark past.  Again, he's right.  What he doesn't say is that psychiatry continues to be dark in many ways related to inpatient care.  Psychiatry is not a money maker -- the resources are not always there for the luxury rooms and pleasant surroundings that might be found perhaps on the orthopedic floor.  And beds are reserved for the sickest of the sick: those who are both ill and dangerous.  We remain the only specialty where pre-authorization for inpatient care demands a life-threatening level of acuity-- if you're not suicidal, you go home.  It means the inpatient units are full very sick people and sometimes there are dangerous, patients may hurt each other or the staff or themselves; it's the sad reality.  And treatment is sometimes dictated by doing what needs to be done in an understaffed environment to keep people safe, even if it means the care is not what is ideal in the long run for the individual patient.  This is not to ruin such a lovely article because Dr. Morris is right (once again)-- psych units are full of tender moments, they are about healing, and they aren't about torture.  Often, they are about pressing the 're-set' button after the power has gone out.

 We're short on beds and negotiating the system is difficult.  It should be easy.  If more people could or would get the care they need, we'd have fewer suicides, less suffering, and fewer people in jails. 

Morris goes on to say: 


Overcoming the stigma against psychiatric units won’t be easy. But I think it’s possible.

Familiarizing the public with psychiatric care is a first step. Stereotypes against psychiatric units endure when these places remain unknown and out of sight. By opening up about the realities of mental-health treatment, providers and patients can address the pervading views of the “psych ward” as a place of torture and imprisonment. This kind of transparency can illuminate psychiatric care’s potential for healing rather than horror.
Bravo!

Tuesday, July 18, 2017

Swiping for Therapists


Over in The New York Times, Melissa Miller has an article titled "How to Find the Right Therapist."

Miller compares it to dating, and she makes the very valid point that good chemistry helps, it's really nice to like and respect your psychotherapist, and to feel a sense of rapport.  In psychotherapy, the talking is an integral part of the treatment and the relationship itself can be healing.  So it is important in therapy that the patient be comfortable confiding in the therapist, be open and honest, and feel safe saying things that can make one feel vulnerable.

Miller compares it to dating, and talks about the pleasure of comparing wedding plans with her finally-found perfect therapist.  She then offers advise on how you, too, can find a good therapist.  

Her advise is awful.  Really.  It's not that some of her points aren't valid, but she starts by giving a quick summary of what type of professional you should see:


Determine the type of professional you need.

If you’re suffering from ailments like panic attacks, depression, post-traumatic stress disorder or obsessive-compulsive disorder, look for a clinical psychologist or social worker rather than a psychiatrist, said Dr. David D. Burns, adjunct clinical professor emeritus at the department of psychiatry and behavioral sciences at Stanford University School of Medicine.
If the issue is something more like bipolar disorder, major depressive disorder, sociopathy, borderline personality disorder or schizophrenia, it’s best to see a psychiatrist or a psychologist with considerable experience in that specialty

I don't know Dr. Burns, whom Miller quotes, but really?  Don't see a psychiatrist for panic attacks, depression, PTSD, or OCD?  But, hey, we apparently do a great job curing sociopathy!  I don't get the division, and I'd suggest that all of those conditions are well-treated by psychiatrists (which may or may not include medications in the treatment).   

Miller advises readers to check therapist reviews on-line.  She doesn't point out that anyone can review anything and there is no way of knowing that good or bad reviews are not verified to be from patients and may be from best friends, ex-lovers, or even the therapist himself.  I'd go for personal recommendations from doctors or known patients myself. And Miller proudly touts that she ghosts her eating disorder counselor and 'broke up' with her therapist by text.  Hmmm.....

Do some research, she suggests, and it seems reasonable to check to make sure the therapist has reasonable credentials and hasn't been sanctioned by a licensing board for something egregious.  A quick telephone discussion is also reasonable, but the author suggests asking the therapist what they like most about being a counselor.   Again, really?  Maybe stick to 'Do you have experience treating my problem.' I'm not sure it's best to start a relationship with a therapist by inquiring about their personal motives for going to work each day; much as I love my work, being asked what I like best about my work by a stranger looking for treatment might make me feel like a college student being asked that wonderful question of "where do you see yourself in 10 years."  

She goes on to address issues of insurance participation and finances.  She suggests that if it's too expensive that the patient should switch the sessions to once a month (not necessarily a bad idea, but shouldn't the therapist be consulted?) or use Skype or email for sessions -- and why would Skype be cheaper?  And how would email work?  She goes on to quote Michelle Katz, a nurse/health advocate:


“They become family to you, so you can ask them to work on a payment plan,” Ms. Katz said.

“Anything is negotiable, and if a therapist is not willing to negotiate with you, especially after you’ve been with them for a while, it’s probably not a good match for you,” Ms. Katz said.

 Finally, Miller talks about timelines for treatment and quotes Dr. Burns again:
“If my son or daughter were depressed, I’d want them to go to a therapist who can get them dramatic improvements in just a few sessions, not just have them pondering their life for months or years without change,” he said.

Rapport is important; feeling cared about, feeling comfortable-- these are all good.  Competency is also important, and Miller doesn't address this beyond a minimal level.  She talks about looking for a therapist like looking for a date, and she assumes the date has no needs of his own: that every patient's a great catch who every therapist would be thrilled to have.  But mental health care is often limited by huge demand, and therapists might not negotiate rates because they have mortgages, student loans, childcare, and food costs.  It's a give and take -- skype and email sessions might not be in the patient's best interest or convenient for the therapist.  And if you call my office, before you even know me, please don't quiz me on what I love best about my job.  Just sayin'.  


So finally, if you want my thoughts on how to find a psychiatrist, I'm going to link you back to an old Shrink Rap post: 
http://psychiatrist-blog.blogspot.com/2010/10/how-to-find-psychiatrist.html

Saturday, July 08, 2017

The Interesting Thing About Reviews of Committed.....


Hello!  It's been a month since the last Shrink Rap post, and it's now summer.  I love the long days and the slower pace.  There have been many times when I have read something and have thought, 'I want to write a blog post about that....' but then time gets the best of me and I end up tweeting it instead. I do believe my brain has reduced itself to 140 character thoughts.  Please do follow me on Twitter at https://twitter.com/shrinkrapdinah

As you may know, ClinkShrink and I are the authors of Committed: The Battle Over Involuntary Psychiatric Care, released by Johns Hopkins University Press on November 1st.  The last few reviews of the book have reminded me how divisive the topic can be.  While all the reviewers have talked about the book as being readable and dressed in the stories of people, the reviewers themselves have opinions on the topic and let them be known.  Let me tell you more.

In Committed, we talk about the anti-psychiatry groups, and we give a voice to those who feel psychotropic medications are ineffective, harmful, or even the cause of psychiatric symptoms.  Reviewers from these groups have invariable noted that, as psychiatrists, we go on to write about the different aspects of forced care with the supposition that psychiatric treatments work, and we don't do a comprehensive challenge of their efficacy.  These reviewers are right: our combined 50+ years of experience is that our treatments are helpful to many people, and we limited our perspective to that of involuntary care. We were not interested in writing a book that questions the efficacy of the treatments -- that's been done by others, and the idea that psychotropic medications don't help everyone or cause some people to have intolerable side effects, is something we discussed in our first book, Shrink Rap: Three Psychiatrists Explain Their Work

On the Mad in America website, Dr. Sandra Steingard starts her review with: 

Dinah Miller and Annette Hanson are two of the three psychiatrists who blog at Shrink Rap. After I started blogging, I began to search out other blogging psychiatrists and I found them. They also have articles published in Clinical Psychiatry News. My impression is that they are decent, well-meaning, and thoughtful psychiatrists (not unlike most of the psychiatrists I know) who want to demystify our profession. Their writing is clear, straightforward, and accessible. Like me, they are all practicing psychiatrists and they deal with the pragmatic challenges we face in our daily work. They offer critical views but they overall seem proud of their profession and their careers. While I respect their work, in that area we seem to differ; they do not seem to be burdened by the professional existential angst that besets me.

On one topic we agree — the subject of involuntary care is the most vexing, contentious, and troubling topic for psychiatry. To their great credit, they have directed an enormous amount of attention and effort to this subject in their latest book, Committed: The Battle Over Involuntary Psychiatric Care. 

I found it interesting that later in her review, Steingard talks about the concoction of medications that Eleanor (the patient against involuntary treatment) was placed on in the hospital -- she calls it a 'shocking cocktail" and talks about our 'unexamined confidence.'  Ah, Dr. Steingard wasn't there for our behind-the-scenes discussion, or for the article that came out of this particular discussion-- Questioning Psychiatry's Assumptions About Lifelong Antipsychotics-- it was far from unexamined.  I was astounded by the cocktail of medicines-- in the Clinical Psychiatry News article, I refer to it as 'enough medication to drop a Clydesdale-- but in criticizing it for Committed, Clink felt we were throwing the treating psychiatrist under the bus.  We decided to report the cocktail and leave it to any reader in the know to be shocked (as we were), and suffice it to say, this was not a combination of medications we could imagine prescribing.  Does that make it wrong?  Eleanor, as the chapter notes, had many side effects, but she also got better.  While I don't advocate this particular cocktail, we decided it wasn't fair to comment on another doctor's prescribing when we weren't there and the patient ultimately got better --though not with her own share of distress and trauma from the admission.  The Monday morning quarterback always play the game better.

On the other side of the debate, Dr. Lloyd Sederer has posted his review of Committed on the Psychology Today website. Sederer starts by talking about the topic in broad terms:


Americans act as if they have a covenant that demands of them considerable liberty and privacy. These warranties have, at times and in my opinion, exceeded other warranties such as public safety and the public’s health – sometimes even common sense.
Sederer's perspective, as you might imagine, feels to be more pro-involuntary treatment, although he goes on to say that the pendulum needed to swing away from a doctor-knows-best stance, then he asks if it has swung too far. He goes on to write:

This is the important question and challenge that Drs. Miller and Hanson have undertaken in what is an exceptionally intelligent, clear, readable and well researched manner. They do have a POV (point of view), which they express early on and weave into the book’s narrative: they call for “…the judicious and limited use of involuntary and humane psychiatric care, as a last resort, after every attempt has been made to thoughtfully engage patients in accessible, kind and comprehensive services on a voluntary basis.”  

Their book first describes the “for” and the “against” arguments for involuntary treatments. They have tapped the nation’s authorities on these subjects so we gain access to the clearest and most informed of sources. Then comes a section on “Civil Rights”, where we learn about the history and processes of commitment laws. The authors then turn their attention to hospitals (general, public and private hospitals), and their delivery of emergency room, inpatient, crisis and outpatient care. They handle this (in fact, all material) in a story-based manner with abundant actual clinical examples, using pseudonyms to protect privacy. It is like we are there to share the dilemmas that patients, families and clinicians face in profound and uncertain ways.

We have been pleased: the reviews of Committed: The Battle Over Involuntary Psychiatric Care have been uniformly positive from both sides of the battle field.  It is, as we knew, a book that everyone might hate: for the pro-involuntary care side, we don't take a strong enough view; for the anti-forced care side, we are not critical enough of our field.  Again, thank you to all the reviewers, and to all of our blog readers who contributed to the book, and to those who inspired us to write it!

Are there messages I'd like to get across?  Yes:
  • Be kind to the patients.
  • Patients may be traumatized by involuntary care, so it should not be undertaken lightly.
  • Forcing treatment won't cure society's problems, but there are times when it may well help the individual involved.
  • It's kind of crazy that we put so much emphasis on debating forced care when there are so many people who want the treatments we have to offer but can not access them voluntarily. 
  • Our mental health system is a mess and forced care is a very complex topic.  
If you want to learn more about Committed, do visit our website at CommittedBook.com

Finally, I am going to change the topic and send you over to Pete Earley's blog.  I recently wrote about the  NAMI elections and how they were really about involuntary treatment.  Since then, the elections have happened, and Pete writes about the results in NAMI Elects New Board Members But Not Without Controversy

Tuesday, June 06, 2017

NAMI: or It's All in the Words....


As I mentioned earlier, I've written a post over on PsychologyToday about how I believe the upcoming NAMI election and the question of whether NAMI will cover a 'big tent' or a 'small tent' -- a focus on severe mental illness versus all mental illness-- is about forced psychiatric care.

One the candidates for office, DJ Jaffe, responded to my PsychologyToday post and said it's wrong, and I should change it. It's an opinion, not a statement of fact, so I'm hanging out with my first amendment right to free speech.  Mr. Jaffe included his whole campaign speech and you're welcome to check it out.  His contention is that in broadening the tent to include all, the SMI  (serious mental illness) agenda has been pushed out into the rain, not included, and goes point-by-point through why this is so.  I'm moving the discussion here because it's an easier venue for me to negotiate (PsychologyToday has a more difficult template and requires editorial approval).

Just some thoughts: 
Mr. Jaffe writes:
For example, in almost all their communications NAMI National has replaced the phrase “mental illness” with the phrase “mental health conditions” as if mental illness were a dirty phrase not to be uttered in polite company. 


My feeling is that I'm a psychiatrist and I treat psychiatric conditions, just as a dermatologist treats dermatologist conditions, or one might see a nephrologist with a kidney condition.  Mental health conditions, mental illness, psychiatric disorder.  The truth is that we don't really have a definition for this: DSM-V has nearly 300 diagnosis, it's easy to get into a box if you want.  The SMI folks tend to focus on diagnosis as though it's absolute and accurate and each one has a uniform prognosis, specifically schizophrenia, bipolar disorder, and severe depression.  Diagnosis can be wrong, it can have a variety of prognoses, and other illnesses-- such as severe obsessive compulsive disorder, severe anxiety, and eating disorders --can be terribly disabling and can cause incredible psychic torment.  "Minor" problems such as adjustment disorder, can result in suicide.  My pet peeve is with calling psychiatric disorders "behavioral disorders."  Many of the people I treat are lovely human beings who behave just fine, thank you.

Mr. Jaffe says that anosognosia is far more important than access to services in keeping people from getting care.  Clearly, Mr. Jaffe has not tried to get care using his public insurance at a clinic in Baltimore. 

Finally, in terms of words, I'm told that it's objectionable to those who advocate for the SMI population to use the words Hope and Recovery.  Who could be against Hope?  Who wants to go see a psychiatrist to be told there is no hope, that they will never get better?   Of course people get better, why else would they come?  All better?  What does that mean?  Most people experience a decrease in symptoms.  Many find that therapy helps them to understand their issues and communicate in a more functional manner, which makes their lives go more smoothly.  (Oh, but much of SMI advocacy is about medications with little thought to therapy).  Many people come in looking horribly sick, tormented and suffering,  and then do get better:  they return to work or to school or to having meaningful relationships.  It often takes time; it's unfair to tell people that they won't get better and have a poor prognosis because we just don't know.    SMI often gets to be about forced medications, and distress about homelessness and incarceration.  If you want people to be housed, might I suggest providing them with housing?

And finally, I am perplexed that NAMI objects to the term 'suffering.'  It's an important word for the sake of helping to convey your psychic pain to another human being, and I often ask people if they are suffering or tormented, and those who look quite well, often say yes.

Ah the words.  So much power to injure, but these particular words don't have much power to heal. 

Monday, June 05, 2017

NAMI's Upcoming Elections: Is It All About Involuntary Psychiatric Care?



Ah, so first visit Pete Earley's blog.  His last two post talk about the upcoming elections for NAMI's Board of Directors.  Big Tents, Small Tents,  a letter from the President of the Board, he's got the issues outlined.

I throw in my two cents over on Psychology Today's website: This discussion of who NAMI should serve-- those with severe mental illnesses and their families, or those will all mental illnesses?--is really about forced psychiatric care. Read my thoughts HERE and I'd love to hear what you think.

Wednesday, May 17, 2017

Join Us At APA!

It's days away: the American Psychiatric Association's Annual Meeting will be in San Diego.  I'd like to tell you about the talks we'll be involved in and invite you to come listen and participate. Please do come say hello!
--------------------
To search for sessions by topic or presenter, go to this link:
http://s4.goeshow.com/apa/annual/2017/itinerary_planner.cfm

 
Session ID: 3019 Symposium
 Outpatient Commitment: A Tour of the Practices Across States
Date: Tuesday, May 23
Time: 8:00 AM–11:00 AM

Speakers:
Chair: Dinah Miller (Maryland)
Presenter: Ryan C. Bell, M.D., J.D. (New York State)
Presenter: Kimberly W. Butler, L.C.S.W., M.S. (New York State)
Presenter: Adam Nelson, M.D. (California)
Presenter: Erin Klekot, M.D. (Ohio)
Presenter: Mustafa Mufti, M.D. (Delaware)
Discussant: Marvin S. Swartz, M.D. (North Carolina)


                           ______________________________

Session ID: 2284  Workshop

Are You a Sitting Duck Online? What You Can (and Can’t or Shouldn’t) Do About—and Avoid in the First Place—Negative Reviews by Patients

Date: Tuesday, May 23

Time: 1:30 PM–3:00 PM

 

Speakers:

Chair: Robert Hsiung, M.D.

Presenter: Paul S. Appelbaum, M.D.

Presenter: Dinah Miller, M.D.
                 _____________________

Session ID: 3010 Symposium

 The Battle Over Involuntary Psychiatric Care

Date: Wednesday, May 24

Time: 2:00 PM–5:00 PM

 

Speakers:

Chair: Dinah Miller, M.D.

Presenter: Roger Peele, M.D. (in favor)

Presenter: Paul S. Appelbaum, M.D. (APA's views)

Presenter: Elyn R. Saks, J.D. (Saks Institute for policy, law, and ethics)

Presenter: Al Galves, Ph.D. (MindFreedom International)

Discussant: Annette Hanson, M.D.
For more information about this session, read HERE.

--------------------------
Measurement-Based Care: Using Multidimensional Assessments to Drive Improvements in Outcomes in Integrated Care Settings 
Rapid Fire Talks Focused on Behavioral Care
 May 22, 2017  Room 27
1:30 PM - 1:50 PM
Presenter: Steven R. Daviss, M.D.




Sunday, May 07, 2017

Negotiated Rates: What No One Talks About in Health Care Legislation


Last week, the House of Representatives passed legislation for the American Health Care Act, the first step in repealing the Affordable Care Act, or as some would call it, Trumpcare versus Obamacare.  The American Psychiatric Association and the American Medical Association (and many other medical societies) oppose the new legislation.  An enormous concern is that the new legislation won't require insurance companies to cover preexisting conditions, or require coverage for mental health treatment or prenatal/maternity care.  Over the coming years, the new legislation is predicted to leave 24 million more Americans without health insurance coverage.

There are many criticisms of the ACA, one being that it forces people to pay for care for illnesses that they don't have and many will never get.  I'm not sure why no one talks about policies where people can opt out of having coverage for cancer. Cancer is a very expensive disease, and not everyone gets it.  If you believe you're at low risk, why should you have to foot the bill for someone's lung cancer any more than you should have to foot the bill for your neighbor's episode of depression?  

Sarcasm aside, I wanted to talk about something that I don't see discussed anywhere.  One huge and accurate criticism of the ACA is that premiums are high and deductibles are high.  I'm not a fan, and it leaves people angry that they pay so much for health insurance and get so little out of it.  But there is something missing in this discussion: if a person has health insurance and they see a doctor, have a procedure, have a lab test done, or get a scan, then the cost to the patient is the cost that has been negotiated by the the health insurance company, and it's remarkably lower than the cost to that a person with no health insurance. The craziness of our current health care system is that the people who can most afford to pay for their care are the ones who pay the least.  So the high deductible may mean that a person pays for his own care, and only sees the benefit of being insured if there is a catastrophic illness, but it also means that while paying for that high-deductible care, out-of-pocket care non-catastrophic costs much less than the uninsured person pays.  It's a crazy system where the poor subsidize the rich -- if a hospital will much lower fees from an insured person, why not accept those same lower fees from someone who doesn't have insurance?   Does requiring people to purchase health insurance even out in the end?  Not for those who are healthy: it leaves the "well" subsidizing the "sick," which in my opinion is better than the "poor" subsidizing the "rich." 

No answers here.  I don't believe that health insurance should be allowed to exclude those with pre-existing conditions: it dissuades people from getting care for fear of acquiring this label, and it provides a service that only the healthy or financially comfortable can afford.  It's not even clear to me what defines a pre-existing condition: 23% of women in their 40's take an SSRI, do they all have a preexisting condition?  If you told your doctor you were struggling with stress during a difficult time and she jotted "anxiety" on as a diagnosis once, does that mean you have a condition?

 For catastrophic conditions, the taxpayer ends up with the bill anyway: before the ACA, if your car crashed or you were diagnosed with cancer or you ended up in the ER in a psychotic state, you were treated. Then you went bankrupt and got Medicaid; this didn't help anyone.  If we can pick and choose, like playing Russian roulette with our health, well, I might not want to pay for your prostate cancer treatments any more than you wanted to pay for my maternity benefits, and I've never smoked, so I may be willing to role the dice on not getting lung cancer. Insurance is about diversifying risk. Mental health, addiction, and maternity services need to be part of the deal and you shouldn't get to pick and choose what health conditions you think you might get.  

We need a mechanism beyond employer-based health insurance to care for those who are self-employed or who work at part-time or contractual jobs; we shouldn't have a situation again where someone in a family must work for an institution large enough to provide health benefits.  Our young people today are not all poised to go straight from college to a job with health insurance; continuing family coverage until age 26 for this mostly health group of young people makes sense.  For those in higher income brackets, it may make sense to charge more for family coverage for each adult child over age 21, but I've not seen that option mentioned anywhere.  Finally,  and perhaps most importantly, Trumpcare decreases funding to Medicaid: it denies the poorest among us health insurance, and as Mr. Trump might tweet: BAD! I can't see a way that leaving those who can least afford care uncovered would be cost-effective.

In all fairness, the administrative hassles of the ACA have not been good: they've diverted doctor time away from patient care and we have physician shortages. But perhaps the answer is to fix the troubled legislation that we have, not to start over. Personally, I think we should look to other countries and see if we can figure out what we're doing wrong: the US has the highest health care costs, and our results don't support this, we have the 46th longest life-span.  Not so good for the greatest country on earth.

Monday, April 03, 2017

Roy on the Pros and Cons of Medical Marijuana


Medical marijuana was legalized in Maryland two years ago, and this summer we will be getting our first dispensaries.  Psychiatrists are starting to ask what this means in terms of treating patients.  Roy did a great job summing up some of the research for our colleagues:

Unfortunately, because of the many historical restrictions on research, there is increasing amounts of data available, yet few "facts" to go by ("fact" as in "a thing that is indisputably the case"). These data are often viewed from differing perspectives. Such as absolute vs relative risks. Harm reduction vs harm avoidance. Public health vs criminalization perspectives. Use vs abuse (eg, plenty people use alcohol without abuse it, getting drunk, rotting their liver... same with cannabis).

That being said, the National Academy of Science and Medicine just put out in January a comprehensive (500 pages) report on the health risks of cannabis. I have attached the 3MB pdf file for our MPS readers' enjoyment. They found about 10,000 relevant abstracts to review (leaving out another 10,000 that did not meet their quality review). I was surprised there was that much out there. 

I'll boil it down to the Executive Summary level. Their major conclusion appears to be that, essentially, we need more research. Beyond that, they divided up additional findings based on the strength and quality of the research:

Strongest evidence:
There is conclusive or substantial evidence that cannabis or cannabinoids are effective:
  • For the treatment of chronic pain in adults (cannabis) (4-1)
  • As antiemetics in the treatment of chemotherapy-induced nausea and vomiting (oral cannabinoids) (4-3)
  • For improving patient-reported multiple sclerosis spasticity symptoms (oral cannabinoids) (4-7a)
Moderate evidence for:
  • Improving short-term sleep outcomes in individuals with sleep disturbance associated with obstructive sleep apnea syndrome, fibromyalgia, chronic pain, and multiple sclerosis (cannabinoids, primarily nabiximols) (4-19)
Limited evidence for: 
  • Increasing appetite and decreasing weight loss associated with HIV/AIDS (cannabis and oral cannabinoids) (4-4a)   
  • Improving clinician-measured multiple sclerosis spasticity symptoms (oral cannabinoids) (4-7a)
  • Improving symptoms of Tourette syndrome (THC capsules) (4-8) 
  • Improving anxiety symptoms, as assessed by a public speaking test, in individuals with social anxiety disorders (cannabidiol) (4-17) 
  • Improving symptoms of posttraumatic stress disorder (nabilone; a single, small fair-quality trial) (4-20)
Limited evidence of a statistical association between cannabinoids and: 
  • Better outcomes (i.e., mortality, disability) after a traumatic brain injury or intracranial hemorrhage (4-15)

The above is from the first page of about 10 pages of summary findings, including findings of both benefit and risk that are in the Exec Summary of the document. If still interested, turn to pages 13 to 22 to read the rest. And dive deeper if you are really interested. 

As for patient education, I think one could turn these 10 pages into maybe 2 pages of "here is what we know and here is what we don't know". Of course, where one draws the dividing line is arbitrary, but start with those things that have the strongest evidence, with benefits on the left and risks on the right.

Then people make up their own mind, like anything else... a risk/benefit discussion. Would you risk liver failure for headache relief? Here's two Tylenol (or four or six).

Sorry if you were looking for a simple answer.