Tuesday, June 30, 2015

Your Kidneys or Your Sanity: Two Bad Options

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

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

Lowe writes:

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

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

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

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

Wednesday, June 24, 2015

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

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

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

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

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

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

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

He goes on: 

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

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

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


 

Tuesday, June 16, 2015

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

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

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

2h2 hours ago

Monday, June 15, 2015

Dressing the Part

 


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


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

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

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

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

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

Maybe a female or gay male therapist would have had an easier time addressing this topic with Greta. But for me, as a straight male working with a straight female patient, every option seemed blocked. Basically, no matter how I tried to put it, I would be saying, “I find you unappealing.”
Which, at least to Greta, would have raised the reasonable question, Why on earth would she want me to find her appealing? The whole thing reeked of grossness.

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

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

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


 

Sunday, June 07, 2015

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




A few things from around the web:


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

Over on the Marshall Report,  former APA president Jeffrey Lieberman gives his opinion on the notebook the Aurora shooter mailed to his student counseling center psychiatrist before he killed innocent people in a movie theater.   Based on his review of the notebook, Lieberman was able to conclude:
His chief complaint and reason for seeking help at the university health center was related to interpersonal issues and anxiety. He does not reveal what would be considered psychotic symptoms. The major issues are his alienation, disaffection, isolation, fear and anger. No mental disorder is clearly apparent. 

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

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

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

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



T

Tuesday, June 02, 2015

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


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

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

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

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



Saturday, May 16, 2015

Shrink Rappers at the American Psychiatric Association's Annual Meeting in Toronto, May 2015

A
APA starts today and I'm updating the list of talks we'll be giving.  Roy is already in Toronto for the APA assembly.  We will  be doing the same talks as I had previously posted, but some of the other speakers in our symposia/workshops have had to cancel, so here is the updated schedule.  Any suggestions for restaurants or fun sights in Toronto will be much appreciated!


I'd like to invite you to come here us speak at this year's annual meeting in Toronto.

We will be speaking at the following symposia and workshops:

Value in Mental Healthcare: What Does It Mean, and Who Decides? - Symposium
 Toronto Convention Centre - South, Level 800, Room 801 A,  
 2:00 PM - 5:00 PM, Monday May 18th

Speakers:
Robert Roca, MD, MBA, MPH
  --Value: Medicine's Holy Grail
Benjamin Liptzin, MD
   --Value: Perspectives on Outcomes and Costs
Henry Harbin, MD
   --Measuring Outcomes Using Standardized Tools: Why It's    
      Important and How To do It
Dinah Miller, MD
 --Value: What Matters to the People We Treat?
Sunil Khushalani, MD
  -- Eliminate Waste, Improve Value
Steven Sharfstein, MD
   --Discussant 
-----------------------------------------------------------------------------
- Are You a Sitting Duck Online? What You Can (and Can't, or Shouldn't) Do About Negative Reviews Your Patients Post About You-Workshop

Toronto Convention Centre - South, Level 700, Room 711, 9:00 AM - 10:30 AM, Tuesday May 19, 2015;

SCHEDULED AGENDA

 Introduction to review sites: John Luo, MD
 Personal experience of negative review: Dinah Miller, MD
 Small group exercise
 Constructive responses by individual psychiatrists and the    
    psychiatric profession:  Paul Appelbaum, MD 
 Future directions: Laura Roberts, MD
 Q and A
_________________________________________________________________

Practical Privacy Issues 

Wed, 5/20: 11:00 AM  - 12:30 PM
11:00 A.M. Sessions

Metro Toronto Convention Centre -Level 800, South Building 

Room: Room 802 A-B 


Presenters:  

~Paul Appelbaum, M.D.,  NY State Psychiatric Institute 

~ Erik Vanderlip, M.D.,M.P.H. University of Washington

~Lori Simon, M.D.

~Steve Daviss, M.D.    FUSE Health Strategies LLC


Objectives:


  • List issues related to electronic health records and HIPAA and other laws and regulations and how to cope with them.
  • Describe how to avoid computer and technology operations that increase the risk of confidential data being stolen.
  • Take steps to limit risks of financial data being stolen apart from other steps to safeguard patient-specific sensitive data.
  • Describe how to use psychotherapy notes to maintain privacy. 
___________________________________
National Action Alliance for Suicide Prevention: Recommendations for Prevention From the Suicide Attempt Survivors Task Force Report--Symposium
 Toronto Convention Centre - South, Level 800, Room 803 A/B, 2:00 PM - 5:00 PM


ABSTRACT:
The stigma around suicide is often associated with whispers or silence, despite the fact that prevention of suicide is a national priority. The National Action Alliance for Suicide Prevention
convened a national task force of suicide attempt survivors last year, releasing a groundbreaking, federally funded report called The Way Forward. The goal of this report is to provide a framework for national, state, and local stakeholders to use when developing resources and initiatives to prevent suicide as part of the National Strategy for Suicide Prevention.
This groundbreaking report identified eight Core Values and seven Recommendations that are helping to catalyze major changes in the national approach to suicide prevention and response. The
speakers will discuss ways in which clinicians and others can bring the report's recommendations to life and open channels of communication and awareness around the topic of suicidal thinking.


Chair: Steven Daviss, MD
Discussant: Dinah Miller, MD

THE NATIONAL SUICIDE PREVENTION LIFELINE
: John Draper, Ph.D. : Project Director for the National Suicide Prevention Lifeline


LIVED EXPERTISE: INNOVATIVE PROGRAMS, INTERVENTIONS AND SUPPORTS FOR PEOPLE EXPERIENCING SUICIDAL INTENSITY INFORMED BY LIVED EXPERIENCE
Presenter: Eduardo Vega, MA




Finally, Dr. Hanson will not be presenting at APA, but she will be presenting at the American Academy of Psychiatry and the Law meetings in Toronto earlier in May.  We will post her schedule once it is finalized.   

Thursday, May 14, 2015

Per Twitter: Dear Dr. Lieberman and others.....


 Oh my. So over on my Twitter account, I tweeted a tweet that has now been favorited, retweeted, mentioned, ?distorted, and tagged such that I've received over 30 notifications on all sorts of stuff I'd rather have nothing to do with. 

So let me start the story at the beginning.  Earlier in May, the New York Times ran a column called This is My Brain on PMS.   It was a first person account of someone's mental anguish and emotional instability during the premenstrual time.  

Jeffrey Lieberman is a former APA president, the chairman of psychiatry at Columbia, and author of a new book on the history of psychiatry called "Shrinks."   Dr. Lieberman has previously tweeted sentiments that indicate that he wishes the NY Times would publish more science-oriented psychiatry articles and devote less precious space to these "opinionator" pieces or to anything with a sentiment that is critical of psychiatry, although I understand his book is rather critical of psychoanalytic practice.   It's hard to know what is in someone's heart in 140 characters, and Dr. Lieberman posted the following tweet:

I guess the introspections repeatedly published by do provide 1st person accts of disorders



Why is a patient's narrative of their difficulties 'narcissism'? . Perhaps public accounts are destigmatizing.







Tuesday, May 12, 2015

Writing about Patients -- or Not


CouchNovelist and psychoanalyst Lisa Gornick has an article in today's NYTime Opinionator, Why I Never Write About My Patients.  She talks about how she ended her career as a psychoanalyst when her novels became successful.  First a leave of absence, then the separation became a divorce.

Gornick writes:



During the years when my stories appeared only in obscure literary journals, never seen by any of my patients, the marriage between my occupations was comfortable. With the publicity that accompanied the publication of my first novel, in 2002, however, many patients became aware of my writing. I knew that whatever responses they might have were “grist” for the therapy mill, but I also knew that just as dreams are transformations of the unconscious of the dreamer, literary works plumb their authors’ inner lives. Analytically oriented therapists such as myself use our responses in sessions as a way of understanding our patients — in a sense, lending our unconscious for the purposes of the treatment. But adding my patients’ responses to my novel into the mix — having my characters, with their links to other corners of my unconscious, in the treatment room — risked, I feared, both clogging the therapeutic mill with too much grist and inhibiting my writing work out of concern for its impact on my patients.

I stopped taking new patients, gave my current patients 18 months notice (sufficient time for nearly all to complete their treatment) and commenced an extended leave.


Eight years later, I tested the waters for returning to my practice — only to discover that the separation should be a divorce. With many of my stories and essays and interviews now available online, and with new mores in which there is no hesitation about looking up anything about anyone, I felt too exposed.
 I'm not one for writing about my own patients, it just doesn't seem either necessary or right, so I can relate to Gornick's concerns.  But when it comes to the analytic belief that the psychoanalyst must be a blank slate whose personal life remains hidden from the patient, then I drift off.  Times have changed and it's hard to remain obscure.  I like social media, and the Internet makes us all so much more more exposed than we'd like to be.  It takes a rare person to ward off every activity that might show up online.  When I think about it, I feel smothered.  In the office, I'm mostly me, but modified to meet the needs of my patients.  In my free time, I'm all me and fortunately the 'me' who lets loose has no criminal convictions.  

Tuesday, April 28, 2015

Some thoughts on Authority and Victimization


This is our blog, and it's my place to vent some, and on this beautiful morning in Baltimore with all the trees in bloom in pink and white, I could really use some space to vent.  While none of us were in the middle of the unrest, it is awful to watch our beloved city on CNN -- this isn't how it should be.
I'm not going to write about riots or police brutality, but I do want to write a little about authority and  victimization, and for that I'm going to ask you to surf over to my friend Pete Earley's blog where he talks about a psychiatric patient who was arrested after biting a nurse in an Emergency Room.  And Pete is my friend, but I may not be gentle here, but I'll trust that he'll still be my friend even if we don't agree about everything.

Before I start, I want to make it clear: I oppose violence of all kinds by all people.  I strongly oppose police brutality, and I strongly oppose  throwing bricks at anyone or destroying businesses and property.  Let there be peace in Baltimore today and tonight and for all days to come. 

  #Black lives matter.  #Blue lives matter.  #Patient lives matter. #Nurses lives matter
 # All lives matter. 

So Mr. Earley wrote a post not long ago titled  We Took Our Daughter to the ER for Help. She Ended Up Being Arrested. 
     A parent writes in:
My daughter was then informed that she was going to be involuntarily hospitalized. She became even more agitated and when she threatened to leave, a nurse confronted her and a scuffle broke out. My daughter was forcibly restrained by five hospital personnel.
The nurse prepared an injection to calm her and my daughter, who was terrified, said: “’I’ll take the pill. I’m scared of needles.” The nurse proceeded to give her the shot anyway and my daughter would later tell us that she went black.
The nurse was pushing her elbow into my daughter’s chest and our daughter bit the nurse’s arm. She didn’t break the skin and there was no blood. 
Our daughter was put in restraints. Her arms and legs were all restrained, so tightly that her hands began turning purple. I thought things couldn’t get worse but they did. Two officers showed up at the ER to arrest my daughter for aggravated battery against the nurse.

The parent continues -- she's angry that the charges weren't diverted to a mental health court because the nurse wouldn't agree to this.  The parent is distressed and doesn't feel her daughter should be criminalized.

When you look at it, this post is rich with material on so many levels and there are so many things to take issue with.  I wasn't in the room, so I don't know if there wasn't some kinder and gentler way of dealing with this patient besides restraining her, injecting her, and escalating her fear and anger.  And really, if the story is accurate, then perhaps it would be reasonable for the patient to plead self-defense, or to press charges herself for the brutal treatment she received (I have no idea if a patient can do that).  Here, however is what Mr. Earley has to say:

"It is even tougher to understand why some victims insist on pursuing charges when the infraction seems so minor, as it appears to be in the case of the nurse who was bitten."

I, like Pete, believe that people in authority need to have special training in dealing with difficult populations and that people should not be unnecessarily provoked.   But we know nothing about the nurse besides the fact that she went to work, did her job (for better or for worse) and was bitten.  I don't know that the right answer here is to press charges, but I also know that it's not reasonable to tell people they need to go to a job every day where they must tolerate being assaulted without any recourse.  Perhaps the nurse had been assaulted numerous times -- mental health staff often are --  and this can lead to a traumatized staff.  I heard one story recently about a psych nurse whose eye was poked out by a new patient on a unit with no warning (~not in the course of restraining someone) by a patient who had a history of violent crimes.

I don't have an answer for this.  People get angry when they are mistreated, and as a society, we've become sympathetic to the victims of an aggressive authority and some people have decided that the resultant violent  response is understandable.    But the assumption is that the person in authority should be focused on doing the exact right thing, even if it means tolerating a work environment where they are in danger, often repeatedly, and that's just part of the deal.  The story above is told from the patient's perspective, not from the nurse's, and her side is dismissed for her lack of understanding and for insisting on pursuing charges for a minor infraction.  The assumption is that those in authority are somehow immune to the traumatization, fear, exhaustion, and if not, they should stay home or find another job.  And actually, perhaps someone who's sticking their elbow into a patient's chest should stay home, but then again, it's a third hand account and and we don't know the details of what transpired in the heat of the moment.

What's my point?  Simply that we're all human and perhaps these stories need to be heard from all sides before judgement is passed.  Perhaps if we could hear from the nurse, we might understand why she insisted on pressing charges, or perhaps we still might think this too extreme a response.  But it does nothing to encourage people to go into the field if you make the statement that they'll need to tolerate human biting without recourse.

Please don't read this as the idea that I'm condoning brutality by anyone.  I'm a huge proponent of kinder, gentler care, and I'm totally opposed to anyone biting nurses.  Some stories, however, lose something when you only hear one side. 



Monday, April 27, 2015

Involuntary Commitment and Suicide: Looking for Stories


As our regular readers know, we are working on a book called --at this moment in time-- Committed: The Battle Over Forced Psychiatric Care.  We're trying to focus on stories and as many people know, suicidal ideas and behaviors are one reason why people get committed.  I'm looking for one or two stories for our chapter about the experiences people have had with forced care and the spectrum of suicidality.  In particular, I'd like to hear from people who feel an involuntary admission helped them or a family member to get much needed treatment.  As always, however, I'll take what I can get.  Please feel free to comment below, or better, shoot me an email at shrinkrapblog at gmail dot com if you'd be willing to share your story in a book.  Obviously, we won't be using patient names or identifying information. 

Tuesday, April 21, 2015

The 29th Annual Mood Disorder Symposium at Johns Hopkins


Today I went to the 29th Annual Mood Disorders Symposium: Back to the Basics.  I somehow have missed the first 28, but this one was really excellent.  Let me give you the quick recap:

 
Karen Swartz, MD talked about "Reasons to Still Love Lithium."  The upshot-- it's very effective in treating and preventing manias and hospitalizations, and it has some anti-suicide properties that hold even for those people where it's not terribly effective as a mood stabilizer.  It works for depression as well.  You need to monitor kidney and thyroid function.  It doesn't work for everyone and everyone doesn't tolerate it.   And we're still learning how to best dose it.

Rosalyn Walker Steward, MD, MS, MBA talked about "The Recognition and Treatment of Depression in Primary Care Settings."  She discussed how most depression is treated in primary care settings and discussed the differential diagnosis for major depression versus grief/demoralization and how a primary care doc approaches diagnosis and treatment.

Lisa Townsend, PhD gave a quick introduction to "Dialectical Behavior Therapy: The Basics and Beyond."  She focused on the importance of recognizing and validating the patient's emotional experience.  

Mr. & Mrs. Jones talked about the patient's perspective of depression.  I have to say, I love when successful people talk about their struggles -- it does so much towards getting rid of stigma.  When psychiatrists and politicians talk about the need to decrease stigma...well, I find it a bit hollow.  So Mr. Jones is very articulate, and very successful despite his difficulties with major depression.

Kay Redfield Jamison, PhD gave a talk called "Writing a Life" and talked about the research she's doing for a book on poet Robert Lowell.  She always has interesting stuff to say.

And finally, poet/historian/atheist Jennifer Michael Hecht, PhD talked about the history of suicide and how she has been impacted by it.  

Some quotes I liked: 

Dr. Swartz: "If someone is taking lithium, you want them to be a partner with you in their treatment." 

Dr. Steward: "SIGECAPS"  Really, there's a mnemonic I'd never heard of?  To assess for major depression: Sleep/Interest/Guilt/Energy/Concentration/Appetite/Psychomotor changes/Suicidality.  It needs an "L" for Libido.  Or two "S's" for  Sex.  

Dr. Townsend: "Your response is understandable and real but it isn't getting you where you want to be." 

Dr. Jamison: "People get treated but they don't necessarily get healed."    It might have been worth the whole day for that one sentence.  

Dr. Hecht: "Poetry is the queen of places to expore new ideas."

Save the date for the 30th Annual Mood Disorders Symposia: 
April 19, 2016.
 
 

Thursday, April 09, 2015

Out of Network Care : Why?


I'm still thinking about what I'm going to say in my talk about value in psychiatry from the patients' perspective.
It seems to me that the question of value and getting one's money worth might include the fact that the cost is different in different settings.  So someone who gets care at a student mental health center, a VA facility, or a public clinic may well pay nothing.  And in private practice, many psychiatrists don't participate with insurance plans  and people may choose see a psychiatrist when they have no out-of-network insurance, and thereby assume a cost of hundreds of dollars per session.

So my question for now is quick, and again, it is meant only for people who have been patients.

Why do you see a psychiatrist who is not in your insurance network?  If this costs more than going with an in-network psychiatrist, what makes the extra cost worth it?

Wednesday, April 08, 2015

Do You Google Your Psychiatrist?



In psychoanalysis, one of the important principals is that they analyst is a so-called 'blank screen' for the patient to project his/her issues on for examination.  It requires that the psychiatrist remain a bit anonymous, and from this we have the tradition that the exchange of information goes one way in psychotherapy.  There are other, more bland reasons for this as well-- the therapy should be about the patient and the sessions should not be about the psychiatrist, and the doctor is entitled to  privacy.  Different psychiatrists address personal questions in different ways, and I'll tell you that most of the time, I just answer them. I'm neither a psychoanalyst nor a blank screen.

The New York Times opinionator section has an article called -- you guessed it -- Do you Google your shrink? which talks about how Google and the internet have changed the practice of psychiatry.  Blank screens are no longer an option, and Ana Fels writes:

I knew my psychiatric practice was forever changed the day a patient arrived with a manila folder stuffed with printouts and announced that it contained the contents of a Google search that he had done on me. He pulled out a photo of my mother and me, age 7, that had been published in my hometown newspaper; architectural plans for an addition to my house that was never built but apparently was registered locally by the architect; an announcement about my great-grandfather’s becoming editor of Amazing Stories magazine in his old age; and my brother’s history as a college activist.

People are funny in what they want to know.  One patient Googled me before our first meeting and found a review I'd written of a novel on Amazon.  She liked the novel, too, so she decided I must be okay.  Hiding isn't an option anymore.  And patients often know that I write.  I've had Shrink Rap quoted to me.  And the truth is that I am who I am, I can't live my life in hiding or give up writing, blogging, or tweeting because someone might learn something about me. 

So do you Google your shrink?  And what interesting things have you learned?

Tuesday, April 07, 2015

Responses to a Short Survey on Inpatient Psychiatry

147 responses

Summary

Was being treated on a psychiatric unit helpful to you?

Yes, I was better at discharge5738.8%
No, I was the same or worse at discharge9061.2%

Were you admitted as a voluntary or involuntary patient?

I entered as a voluntary patient and my stay was helpful3121.1%
I entered as a voluntary patient and my stay was NOT helpful4127.9%
I entered as an involuntary patient and my stay was helpful2919.7%
I entered as an involuntary patient and my stay was not helpful4631.3%

Was your treatment abusive in any way?

My treatment was kind and respectful to a degree I found reasonable and acceptable5336.1%
I felt I was physically abused by the staff1610.9%
I was verbally threatened by the staff4127.9%
I was treated by staff in a demeaning manner without an obvious reason8457.1%
I was assaulted by another patient96.1%
I was threatened by another patient2416.3%
I was physically uncomfortable because I was denied access to food or restroom facilities in a timely manner2114.3%
I was uncomfortable because I was not permitted to smoke.96.1%
Other4329.3%

Discharge

When I left, it was clear where I would go for follow up and when7853.1%
I left with no clear follow up appointment or plan4329.3%
Upon discharge, I was given prescriptions for medications I was able to obtain5336.1%
When I left I was given prescriptions for medications I could not afford117.5%
My prescriptions lasted until I had an outpatient appointment3221.8%
My prescriptions ran out before my outpatient appointment1610.9%
I never went to any followup1711.6%
I never filled my prescriptions138.8%
 
Comments:
 
i've been discharged to a safe house
I was released with the drugs
It's been 5 months since my hospitalization and I still haven't been able to meet with a case manager. It took 2 months for them to call me and they have rescheduled twice at the last minute.
price of prescriptions almost $400
Due to holidays and no case worker I didn't see anyone until about 6 weeks after discharge.
The meds were so costly, my entire prescription benefit for the year was used up for ONE month's handout, plus I had a $200 copay when I was told it was free (I told the discharge nurse these brand name antipsychotics were too costly, and she said no copay, but I was billed $200 later, and had to pay it)
The diagnosis was inconsistent with diagnosis of therapist and was based on false information from abusive spouse
they didn't set up where I was going of medication changes my regular out patient providers did
that made me worse than before I went in
I was very over medicated, against my instincts, and those instincts were correct once I got a second opinion. I was misdiagnosed with bipolar because I went manic on copious amounts of energy drinks- not because of a biological disorder. The drugs brought me down, but time/sleep during treatment would have done the same!
I only obtained a proper plan after a subsequent episode
I left when my own doc was appalled the treatment
Voluntary, private hospital, late 80s ( was 16), doubt I would have the same positive experience now.
I was already taking meds at the time.
Follow-up plan was poorly devised and seemed just to check boxes.
got out - tapered myself off all drugs - it took some time
One follow up told them was suicidal last I heard of them. Last attempt may of been successful. Hopefully yes but only time will tell and not going to the doctor to find out if I'm dying.
The Psychiatrist changed my perscirptions with disarterious results.
I was order to take oral and injection meds
I was asked to do an exit review but felt it would not be wise to honestly comment as i was worried i would be re-admitted at some point and they would have more ammunition against me.
Became an antipsychaitry activist
so my answer is irrelevant
Like whatever. Fix the damn system tired of losing friends to suicide. I love Billy btw. Loved your book too.
No one explained diagnosis.
I had no choice or options. I was violated.
They actually had me sign papers saying I was safe to leave the hospital when I told them I was no different if not worse ( signed papers with statement that I didn't agree but that I had seen the paper)
the drugs tranquilized for 14 hours straight when taken as prescribed; no information about tapering safely to a lower dose that I could function at was provided
followup prescribed inconsistent with their own diagnosis

What aspect of care was most helpful to you?

The medications1610.9%
The interactions I had with the psychiatrist117.5%
The interactions I had with the nurses42.7%
The interactions I had with other staff32%
The activities provided00%
The food00%
The physical environment42.7%
The interactions I had with other patients2517%
Group therapy and educational groups21.4%
The interactions I had with my family00%
The time I spent in a seclusion room21.4%
The time I spent in physical restraints00%
The opportunity to escape the stresses of my outside life (work, etc)2013.6%
Yoga, tai chi, massage, general healing00%
The coping skills I learned00%
ECT00%
TMS00%
Family visits64.1%
Support animals on the unit00%
Nothing at all was helpful3624.5%
Other1812.2%