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.

Sunday, March 26, 2017

Guest Poster Dr. Maher on Dealing with Changes in Psychiatry Through the Years (But Especially Now)


Obviously, psychiatry has changed over time. We've gone from a field where treatment was mostly psychotherapy-- I'll purposely omit insulin shock, leeches, and lobotomy-- to one of symptoms, prescriptions, and side effects, as though these things occur outside of the context of a person's life.  Ah, you've heard me rant before.  And like all of medicine, it's no longer just about treating patients, it's about checking the right boxes, coding what happened in the session by the minute, those damn CPT codes, and now about the technology and the hits your fees take if you won't e-prescribe, file PQRS (?huh) data, and practice the way the insurers want, if you choose to accept insurance or work for an agency that does.  With all that in mind, I saw this lovely and angsty post on Facebook, and asked the author to join Shrink Rap as a guest poster.  I was so pleased when Dr. Maher said yes.  Her guest post is below.
------

 I'll be 65 next month, I will have been in private practice for nearly 40 years, and I'm trying to decide where to go from here. If you have time, would you help me think through this difficult decision?
I trained in a time and a place when psychiatric treatment, other than for the severe mental illnesses, was about psychoanalysis. Even if you didn't go on for analytic training (which I did, right after residency, at one of the most classical institutes in NYC), your primary goal was to search for and speak to the complex humanity of the other. My 4th year psychopharm course was optional.

Yes, the classical model was flawed in significant ways, but over time I took what I needed from it, I owned it and I loved it.
Then prozac arrived on the scene and I woke up in a different profession. No longer was it about meaning and humanity and insight into who you are, how you got to be that way, and the unconscious forces that led you to get in your own way. No longer was transference the mechanism of action. My field became about symptom constellations, drugs and/or skills to fix what was wrong with you.

This perspective always felt wrong to me, but over time I came to integrate the parts that felt right with the work I was trained to do, and it worked pretty well. I have a very good practice, partially private pay and partially insurance based. Aside from Medicare (helpful when some of your patients have been with you for 30 years), the other insurance I accept is the one that the NYC Dept of Education uses. Many of my patients are teachers, so their psychopathology falls within a range that I'm comfortable treating.

Once long ago, that insurance company called and asked me to take a patient off their hands. She was a paranoid, depressed, obsessional, suicidal, entitled, angry and litigious woman who fired every psychiatrist she saw, called the plan daily and threatened to sue everyone she spoke to. I told them I would only take her if I could see her 4 days/week indefinitely, no questions asked. They said yes, and she never bothered them again.

They left me alone after that. I've seen some people weekly for years without being bothered.

But times are changing, yet again. No one would remember me from that time. No one would bend the rules to allow a shrink with dynamic understanding to engage a patient like that. The billing, coding and documentation requirements, and the medical complexities, are becoming more than I feel comfortable with. I'm finding it increasingly hard to integrate the complex, struggling human being that I see with the symptom and treatment picture that I'm required to see.

I've moved into other arenas, including a not-for-profit organization, documentary filmmaking, and the development of an emotional literacy curriculum for young people. But there's no money involved in any of them. They cost money.

I love my work and I love my patients and I think they benefit from working with me. I know what I know and I know when to refer to to ask for help. When I do psychodynamic "talk therapy" (I hate when they call it that!!), I'm doing something very complex, something I'm very well trained for. But there's no code for that and very little respect for it, and I live in fear of being audited.
If you've read this far, thanks so much. I'd be grateful to hear your reactions.

Friday, March 24, 2017

Committed has a Website



You are cordially invited to visit CommittedBook.com to read about our book on involuntary psychiatric care.  There are links to reviews, radio shows, and some stuff about us and where we'll be speaking.

I hope you like the new website.

And while I have your attention, I'd like to send you to a personal essay in the New England Journal of Medicine by Dr. Adam Hill.  He talks about fighting stigma and his own struggles with depression and alcoholism.  My kudos to Dr. Hill. Medicine is not a gentle world and I admire his bravery in making his struggles so public.

Wednesday, March 08, 2017

Really? Can't we be nicer? Objecting to sending those in mental health crisis directly to jail.


Hi, it's been a while.  I have been ranting in other venues, and caught up a bit in the All-Trump-All-The-Time phenomena.  

So my latest thing to rant about is hospitals that send patients to jail when they don't have beds.  I don't mean people who've committed crimes, I mean people who are in crisis, who are presumed to be a danger to themselves or others.  Here are some of my thoughts:

On Psychology Today's website, I wrote "A simple solution to the bed shortage? Unfortunately, Jail"  The link to that is Here.
Over on Clinical Psychiatry News, I did a little more research on the topic and spoke with the reporter, one of the doctors, and the Rapid City Sheriff. See "Mentally Ill? Go Directly to Jail"
The link to that is HERE.

But I've learned that it's not just in Rapid City, South Dakota where it's an issue -- oh, and the sheriff there is apparently refusing to take these patients -- but other states have these issues as well.  My friend, Pete Earley the mental health advocate has been kind enough to share my outrage HERE

On Facebook, I've noted:

When we submitted our book proposal for Committed, our editor told us we had to take a stance and the message had to be something more than be kind to patients. Lately, I'm thinking that "Be kind to patients" is not such an obvious thing in our crazy world. Last week, I wrote an article about a hospital in Rapid City SD that announced their overflow psychiatry patients would be held in jail (--I researched the article after I first saw it on this FB page, so thank you to the poster). Today I read that in 6 states people in mental health crises can be (and are) held in jail when there are no hospital beds available. These are not people who have committed a crime. Why, as a society, don't we think this is unconscionable? Could you imagine going to the hospital for pneumonia, being told there were no beds so you were going to jail? Why is jail ever an alternative to health care? What is wrong with us?
 Mostly I've been surprised at how little outrage there is, though I hear the APA is now writing an action paper to oppose jailing psych patients. Will that help? Does anyone read APA action papers?  Commenters say, well, most mental health care is given in jail (and, sigh, we seem to accept that as okay), but this is different: these are not people who've committed a crime, these are patients going to an ER for help!  They haven't broken a law, they aren't under arrest.  Advocates want to increase laws to make it easier to force care, how about making it easier to access care in a humane and kind way?

Sunday, February 12, 2017

Still More on Guns and Mental Illness


The issue with mental illness and guns is so hard to explain to people. While there have been mass shooters with mental illness, in very few cases does the "mental illness" serve to explain what happened, and statistically, you should be much more worried about being killed by your spouse, the car next to you on the highway, that extra pain pill you take (especially if you take it with a sleeping pill or a drink), than you ever should be about a mentally ill mass shooter in a public place. Where the numbers of gun deaths rise is when you mix guns with substance abuse, especially in people prone to violence, anger, and impulsive actions; suicide (where people sometimes take action within minutes of making a now-irreversible decision); or accidental deaths where people are careless (which may be higher in people with cognitive problems or who are abusing substances). 

I had an editorial on a proposed repeal of a gun law this week, and the Chicago Tribune wrote on the same issue. Note their emphasis on mass shootings (none of which pertained to this ruling as none of the shooters received Social Security Disability Payments) and it didn't explain why someone would be on disability and might need a payee. Mine was not about violence but about common sense. Obviously I like mine better, but compare and see what you think, same issue, different arguments:
 



If someone has a mental illness severe enough that he cannot work or manage his own money, should he be allowed to own a gun?
chicagotribune.com|By Editorial Board

Friday, February 10, 2017

Assorted Frustrations, Plus a Book and TV Series Review


I've been finding the world to be a frustrating place, and when I'm frustrated, I write.  It could be worse.  I've written a lot this week.  

First I'll send you to a commentary piece I wrote for the Wall Street Journal asking the Senate not to repeal a ruling that prohibits those who are both disabled by chronic, severe, mental illnesses and are unable to manage their finances (often because they are cognitively impaired or have poor judgement.  I would not have concocted nor supported this original ruling under the Obama administration because I don't think mental illness and gun legislation mix, but given that it exists, it's a pretty low bar.  But mostly, I hate that the NRA has the power that it does in our country and that tens of thousands of people die from firearms each year. See: Don't Repeal Obama's Modest Gun Limit.  
If you need to get around the paywall, try going through our Facebook page to the Link: https://www.facebook.com/shrinkrapbook/

For a bit of a break, I reviewed Patrick Kennedy's wonderful memoir A Common Struggle, in the same article with the dark comedy Showtime TV series, Nurse Jackie -- an odd combination, but they are both about addiction.  See Nurse Jackie and Patrick Kennedy.

And finally, I want to rant about using jails INSTEAD of medical facilities for psychiatric patients.  I'm containing my outrage (or perhaps I'm not), but when we hear about correctional facilities being the biggest providers of psychiatric care in this country, we do assume that the people that are being housed there have either committed a crime or are suspected of committing one with pending charges.  Read my short article on Psychology Today about own hospital in South Dakota now sends their overflow psychiatric patients to the local jail.  These are not people who have committed any crime.  In what alternate universe is this okay?   So much for controlling my outrage.
See: https://www.psychologytoday.com/blog/committed/201702/simple-solution-the-bed-shortage-unfortunately-jail

 And while I'm ranting about this, please see Pete Earley's blog about a man who stole $5 worth of candy then spent 101 days in jail waiting for a bed at a state hospital.  His jail term ended when he starved to death his jail cell.  We can do so much better.  

Thanks for listening. 

Thursday, February 02, 2017

Breaking Heroin's Grip: a documentary by Maryland's Department of Health and Mental Hygiene

Breaking Heroin’s Grip: 

Road to Recovery

Airing Saturday, February 11 at 7pm

Breaking Heroin's Grip: LaurenBreaking Heroin's Grip: 
Road to Recovery is a
poignant and personal
 documentary shedding
 light on our region’s
pressing heroin problem.

 Told through the lens of adults that have
 experienced heroin’s grip first-hand, viewers
will get an authentic look inside the complexities
 of this harrowing epidemic.

The program includes a 40-minute documentary
followed by a 20-minute live phone bank offering
viewers expert information about treatment. The
documentary is produced by Maryland Public
 Television in partnership with the
Maryland Department of Health and Mental Hygiene.
The program will be simulcast by numerous broadcasters
 (both TV and radio) in Maryland, as well as surrounding states.

-->
WBAL-TV / Baltimore, MD Channel 11
WBAL-AM / Baltimore, MD Channel 1090
WJZ-TV / Baltimore, MD Channel 13
WYPR-FM / Baltimore, MD Channel 88.1
WMAR-TV / Baltimore, MD Channel 2
WJZ-FM / Baltimore, MD Channel 105.7
WNUV-TV / Baltimore, MD Channel 54
WLIF-FM / Baltimore, MD Channel 101.9
WRDE-TV / Lewes, DE Channel Comcast 9, 209, 809,
       Direct TV and Dish Network 31, Over The Air 31.1
WOLB-AM / Baltimore, MD Channel 1010
WHAG-TV / Hagerstown, MD Channel 25
WWMX-FM / Baltimore, MD Channel 106.5
WMDT-TV / Salisbury, MD Channel 47
WHFC-FM / Bel Air, MD Channel 91.1
WHUT-TV / Washington, DC Channel 32
WJEJ-AM / Hagerstown, MD Channel 1240
WUSA-TV / Washington, DC Channel 9
WPTX-AM / Lexington Park, MD Channel 1690
WITF-TV / Harrisburg, PA Channel Digital: 36 (UHF)
       Virtual: 33 (PSIP)
WITF-FM / Harrisburg, PA Channel 89.5
WTHU-AM / Thurmont, MD Channel 1450
WMPH-FM / Wilmington, DE Channel 91.7
WKHS-FM / Worton, MD Channel 90.5
WRNR-FM / Annapolis, MD Channel 103.1
WOL-AM / Washington, DC Channel 1450
WNAV-AM /Annapolis, MD Channel 1430
WPRS-FM / Washington, DC Channel 104.1