Sunday, July 20, 2014

Does Anti-psychotic Withdrawal Make People Kill?

So here's an interesting article in the Irish Times: Niamh O'Donoghue writes in "Murderer accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court."  I'll let you surf over there if you want to read more, the title says enough for me.

My first thought was :  Really?  People stop their medications all the time, cold turkey, without doctor supervision or approval, and they don't generally kill people.  So how do you know if someone's "symptoms" --like agitation -- are he result of medication withdrawal, or the result of a recurrence of the original illness that the medication was treating?  There's not a great way to sort that one out, but I was befuddled by the idea that one would attribute murder to medication withdrawal.  Maybe that should be on the TV commercials with the list of side effects, "Stopping this medication suddenly can lead you to kill people." 

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at:

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at:

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at:

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at:

Wednesday, July 09, 2014

Shrink Notes: what does your doc think of you?

I've written before about shrink notes back in 2011.  See Here and Here.
With the increasing transparency we're seeing with electronic records, there are now systems that allow patients to access their doctor's notes.  The first time one of my patients did this, he casually mentioned that the record included the wrong dose of a medication, and I suggested my patient might want to tell his doctor about this.  

In psychiatry, we've been a bit touchy about this.  Patients might be distressed to see what we write about them, they may see some of the terms we use to describe them (like delusional?) as being negative.  

The New York Times has an article discussing a pilot study in Boston to give patients electronic access to their therapists' notes.  In What the therapist thinks of you, Jan Hoffman writes: 

The pilot project has raised questions in the mental health community. Which patients will benefit and which might be harmed? How will the notes alter a therapeutic relationship built on face-to-face exchanges? What will be the impact on confidentiality and privacy?
And the project presents difficult choices for those who argue for parity between medical and mental health patients. Should patients with schizophrenia, for example, who may stop taking their medication after reading that they are doing well, have the same access to treatment notes as those with irritable bowel syndrome?
But the lingering underlying question is, do patients really want to know what their therapists think? Dr. Kenneth Duckworth, who is the medical director of the National Alliance on Mental Illness, an advocacy group, said: “I’ve offered to share my notes with patients and they’ll say, ‘No, I’m good.’ But it’s a good concept that should be researched.”

The article goes on to describe the content of some therapist's notes and the impact it has on patients to read it:

He clicked open another therapy note.
Mr. Baldwin “is continuing to try to push himself to get out more and to be more socially connected even while his emotions tell him to do the opposite,” Mr. O’Neill wrote, adding that his patient is “clearly making good, and even courageous, efforts on a number of fronts.”
Mr. Baldwin, who celebrated his birthday recently with a museum lecture, movie and dinner, flushed with pride.

Hmm, I thought.  These are the type of interpretations I made aloud to the patients, they aren't the stuff of my notes, and if they were, I'd be living in the office trying to write accurate process notes of sessions.  A lot goes on in a session, and notes of this type could be very long.  I'd be hard pressed to feel I could prove that someone's emotions were telling them not to be socially connected and to stay inside -- what does that even mean?  Oh, truth be told, I write really boring notes.  In 20+ years no patient has ever asked to read their notes, and if they did, they'd find it a really boring read.

I'd love you're input, but comments are still off while the blog settles down. 


Sunday, July 06, 2014

Guest blogger Dr. Sana Johnson-Quijada on Freedom and Self Care

I met Dr. Sana Johnson-Quijada at the APA Annual Meeting this year in New York.   Sana has her own blog Friend to Yourself, and I invited her to do a guest blog on Shrink Rap.  In honor of Independence Day, she sent the following post. 

Self-Care is Freedom, is Democracy, is Because We Are Accountable

Self-Care Tip #159 – Be accountable for and to yourself.
It was about 100 degrees Fahrenheit, which in my part of the world is considered hot.  But in Washington D.C., I considered that temperature general anesthesia.  I was breathing it in and trying hard to remain alert.  Just when I thought I could hold out no longer, I saw him.  Big and expressive, the long form of Abraham Lincoln was there, surrounded by loud irreverent people.  My brother and I were wiping sweat out of our eyes trying to keep track of our kids.  We wanted to read the Gettysburg Address for our kids, and found ourselves screaming.  The kids could barely hear the words above the disinterested rabble around us.  Despite all this, I was choking; a weepy, sweaty, nearly anesthetized but free American.
Four score and seven years ago our fathers brought forth on this continent a new nation, conceived in liberty, and dedicated to the proposition that all men are created equal.
Now we are engaged in a great civil war, testing whether that nation, or any nation, so conceived and so dedicated, can long endure. We are met on a great battle-field of that war. We have come to dedicate a portion of that field, as a final resting place for those who here gave their lives that that nation might live. It is altogether fitting and proper that we should do this.
Just down the corner from Lincoln is a president’s list of sites to see, informers and reminders of who we are and where we came from.  However, none of them were “my Lincoln” experience.
But, in a larger sense, we can not dedicate, we can not consecrate, we can not hallow this ground. The brave men, living and dead, who struggled here, have consecrated it, far above our poor power to add or detract. The world will little note, nor long remember what we say here, but it can never forget what they did here. It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us—that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion…
A couple of days ago, writing the post about how stress intersects with medicine, I remembered “my Lincoln.”  It may seem like a stretch at first but take a minute.  Self-care is a way of saying, “I am free.”   In places where life is cheap, almost without value, self-care is not much of an option.  It is because of freedom that we can extricate the meddling fingers, the invasions, and be the keeper of our own private spaces however we choose to.  It is because of freedom that we can tell people that although my brain is ill and although I take medication, I am equal. Saying that is self-care.  Saying that is possible if we take that freedom to keep our own accountability for our own selves.  Accountability is not the same as blame.  Having accountability for our freedom is not the same as being at fault for what came before freedom, nor our current conditions.
—that we here highly resolve that these dead shall not have died in vain—that this nation, under God, shall have a new birth of freedom—and that government of the people, by the people, for the people, shall not perish from the earth.
If you’re not accountable to your inner self, if you’re only accountable to your actions, or you’re only accountable to what others determine and define about you, than you are not free.  You are blamed.
Accountability is such a tender privilege.  We might lose it if we forget who we are, where we came from and our rights to freedom.  Democracy is self-care.
Question:  How do you see the relationship between self-care and your freedoms? 
I practice psychiatry and parent, with my husband, our 3 small children.
Woven into this, writing and connection to community continues to bless me.  I am grateful. 

Friday, June 20, 2014

Tired. Just Tired.

For years, I've absolutely loved having  Shrink Rap.  I've loved having a place to write, to vent, to share something cool I've learned, and I've learned so very much from readers who have really changed my life.  What a great experience from a thought at the kitchen table that started, "I want a blog.  What's a blog?"  Shrink Rap has inspired me to keep current with psychiatry and to learn about things to write about that I might otherwise just skip.  I love having a place to ask questions, especially when they're about things that make my brain start doing somersaults (--well, not really, I think it's anchored in there okay).   Someplace to talk about things that are really bothering me or to share a funny cartoon or to just be a bit ducky.  

Sometimes, over the years, I've gotten really annoyed.  As much as I like hearing about others peoples' experiences, I don't like when people generalize their interior world to everyone else. And when it's an incessant, it gets wearing.

Lately,  I'm totally consumed with writing our next book.  I'm meeting the most interesting of people, and it's fine with me that some of them are very much in favor of involuntary psychiatric care, for what seem to be caring and reasonable agendas, and some of them are very much against involuntary psychiatric care, for what seem to be caring and reasonable agendas.  But my brain is consumed with this.

And as much as I've loved Shrink Rap, the drum beat of negative comments and the inter-reader bickering, well, it's tiring.  For a short while, I moderated comments.  That's work, one more thing to do when I should probably be making pesto instead. Roy got tired long ago, and Clink chimes in when something really inspires her, so I've been most of the noise for a long time now.

I'm tired.  Just tired.   We'll see. I think I'm taking a little rest for now.

Monday, June 09, 2014

Is it Ok to Shrink your Sister in an Emergency?

I'd like to bend your ear with a hypothetical situation and see what you think.  This one is for the docs, and I'm going to start and end it with a simple question: is it okay to prescribe for a family member?  Is it okay to prescribe a psychotropic medication for oneself or a family member?  

Before you jump on me, let me tell you that to the best that I am aware, docs have always written prescriptions for themselves and for their family members.  An antibiotic, an allergy medication, I think this has been par for the course for straightforward things.  When I was an intern, one of the nurses asked me to write for an ulcer medication for her mother ---I said 'no' since I'd never so much as seen the mother, but it was uncomfortable for me.  I've heard older and wiser psychiatrists talk about prescribing Valium for themselves, Xanax for a friend afraid to fly, an antidepressant for a parent, and I've certainly had patients who've gotten medications from family members who are docs, including controlled substances.

Somewhere in there, it became taboo to prescribe for family members, particularly psychotropic medications or controlled substances.  In our state, the licensing board sanctions people if they learn about prescriptions written for anyone where there is no chart.  I think.  What's kosher and what's not kosher is a bit of a guessing game, and while obviously it's a problem to prescribe large quantities of Oxy for yourself, I'm not sure if or when it's a problem to refill a spouses' statin when their doc is out of town. 

So let me give you an invented scenario, and I'm curious as to what the docs out there think is the right thing to do.  If everyone else wants to chime in, that's fine, but please say who you are -- doctor, nurse, social worker, golf pro, whatever, no pure anonymous responders, please.

Lucy has a history of panic disorder and five years ago she was treated with medications: first with Xanax for a couple of weeks, and then with Zoloft.  Once the Zoloft kicked in, Lucy was able to stop the Xanax.  Lucy said the panic attacks were horrible, and the medications brought her tremendous relief, and she also had psychotherapy.  After about a year, Lucy tapered off the medications and she has been free from panic attacks ever since.  Until last week.  Out of the blue, Lucy was hit with a horrible attack.  She lives in another part of the country now, and Shrink Brother, visiting for a few days,  took her to the ER, where they ruled out a heart attack, gave her some Ativan, and sent her home with a prescription for ten pills and directions to see a psychiatrist.  

Lucy starts working the phone, but her new town is nothing like her old town.  She calls ten psychiatrists, most have a wait of 4 to 6 weeks.  Shrink Brother also calls around, but he lives in another state-- he's just visiting for the weekend -- and all the shrinks have secretaries that form pretty solid walls.  Weeks, if it's an emergency, she should go to the ER, but Lucy's already been to the ER.  Lucy wants to start back on Zoloft, because she remembers it took weeks to work.  Having moved to town 18 months ago, and being in very good health  until now, she never got a primary care doc or a gynecologist, and yes, she's well aware this is all her fault.  She makes the soonest appointment she can get with a psychiatrist -- 3 weeks, and is told that the shrink sees new patients for an hour, and after that it's a 4 patient/hour flow.  So, she'd like to start on Zoloft, she's still having panic attacks and is due to run out of Ativan, and she also needs to figure out how to get a therapist (plus a primary care doc and a gyn).  Brother shrink is worried about prescribing for her -- he's gone home to his own state and no one will be monitoring sister Lucy -- what if she gets suicidal or manic on the Prozac?  Does he really want to monitor sister Lucy for sexual side effects?  (TMI, he notes) Isn't it a problem for him to write for Ativan, an addictive, controlled substance, for a family member?  Lucy goes to an urgent care center, and is sent out with a script with a low starting dose of Zoloft -- enough to last for 10 days, and ten more Ativan tablets, not  enough to get her to the appointment.  Infuriating given that Lucy had made a point of telling them she couldn't find a psychiatrist to see her for weeks, but when she got to the pharmacy, she realized that the script was too low a dose and too few pills.

At this point, Brother Shrink is totally frustrated.  His sister has now been in an ER and an urgent care center, she has an appointment with a psychiatrist, chosen for the soonest appointment, no clue if he's any good.  Nothing horrible will happen if Lucy goes without medications, she'll simply suffer longer and it's feeling a bit unnecessary when he could phone in some Zoloft and a few more tablets of Ativan to hold her over.  The only other option that either of them can think of is for Lucy to continue to make regular visits to the urgent care center where a doc with no expertise in psychiatry can continue to prescribe, if he feels so inclined.  At the same time, Brother Shrink worries that if there is a bad outcome, now or ever with any of his other cases, it will come out that Brother Shrink inappropriately prescribed to sister.  

What should he do?  Jesse?  PsychPractice? Dr. Reidbord?

Saturday, June 07, 2014

In the Works, "Committed: The Battle Over Forced Psychiatric Care."

Good morning, I've missed you.  Blogging has not been the same lately and I've let some great topics go by. 

 Let me tell you what I've been up to.

There have been so many things to write about lately, and I will tell you that my brain is just bursting with all the work Clink and I are doing on our new book: Committed: The Battle Over Forced Psychiatric Care.  ClinkShrink is doing some of the background stuff, she's being (as always) the forensic expert, she's sweeping up after my grammatical carelessness, and correcting the forensically idiotic things I say.  She's focusing on legal cases and a chapter on restraint and seclusion.  I'm taking the lead on writing some of the other chapters, and her description of this is that it's like trying to keep up with a hamster in an exercise wheel.  That hamster would be me, and I'm having no more luck keeping up with my own thoughts then Clink is, but every now and again, I jump off and take stock.  I started with this very funny idea that I would work on one chapter at a time, and that each chapter might take a month.  Okay, so some chapters are taking a very long time to get the parties lined up for, and I'm working on 5-7 chapters at once.  These days, I'm as much journalist as shrink.

Would you like to hear about the book?  Don't hold your breath on being able to read it anytime soon, but it's making progress and some days the progress is much faster than I expected.

The first two chapters are from the perspectives of patients -- wonderful, intelligent, articulate, people -- one of whom found that involuntary hospitalization was traumatizing to her and left feeling her injured, another  of whom found it help keep her life from disintegrating.  I purposely chose people who had good insight and believable stories -- I didn't want the person who felt her care was unkind to be dismissed; I thought her complaints were valid and warranted a critical look.  Both patients allowed me to access their medical records, and to interview their doctors and family members, so I felt like I got a good sense of what went on.

Since the book is "The Battle Over Forced Psychiatric Care,"  the third chapter is called The Battleground.  This is the most difficult chapter to write to date, just because it's taking time to get together with everyone.  So far, I've interviewed  E. Fuller Torrey of the Treatment Advocacy Center, Ron Honberg of National NAMI, Ira Burnim of The David L. Bazelon Center for Mental Health Law, and an anonymous gentleman from the Church of Scientology in New York City.  I have times set up later this month with Paul Summergrad, the President of the American Psychiatric Association, and Daniel Fisher of the National Empowerment Center (a Recovery Group), and I have been working hard with MindFreedom (a survivor organization) to find a time for a conference call.  Some other great people have chimed in as well: Xavier Amador, Solomon Snyder, and Paul Appelbaum has been helpful every step of the way.  

Chapter 4 is currently on Civil Rights, and it's taken from a news story our readers pointed me to about a woman in Vermont who was held in a hospital for 5 and a half weeks with no hearing.  The case is the springboard for discussion, so I've talked with a wonderful legal aide attorney in Vermont as well as the president of the Vermont Psychiatric Society.  As in many of our chapters, the laws there are changing as we write and the hamster keeps trying to run faster.

Chapter 5 is on law enforcement and how people enter the mental health system through police interventions.  I focused here on Crisis Intervention Teams, and Officer Scott Davis has been a gem to let me ride along with him and share his world with me, and Judge Steve Leifman in Florida has given some wonderful insights and statistics.

Chapter 6 is on the inpatient unit, and the chairman of psychiatry, Dr. Ray DePaulo was truly my hero for allowing me to shadow him on the unit.  Steve Sharfstein, a former APA president and CEO of Sheppard Pratt Hospital talked with me about how his institution works, Dr. Bruce Hershfield a former a superintendent of Springfield State Hospital, shared his insights with me, and I had a present-day tour of the state hospital, which now houses 230 people, down from a high over 3,000. 

In short, lots of lunches, and lots of insights from really brilliant people.  

Clink is working on Chapter 6: restraint and seclusion, and the plan down the line is to look at the legal system through the public defender's office,  outpatient commitment, violence and mental illness, guns and mental illness, maybe forced ECT, maybe indefinite confinement of sex offenders (we'll see), and a little more focus on both families and legislation.  Jeff Swanson at Duke has provided invaluable guidance, and I've grown very fond of these folks at Penn from The Scattergood Program for the Applied Ethics of Behavioral Healthcare -- and I'm looking forward to spending more time with Candice Player, and John Monahan, once I finish the current chapters and more forward.  For my brief blog post, there are many many people missing, but I wanted to give some quick shout outs and just an update on the quite nature of Shrink Rap these days.

What do you think?  Obviously our blog readers have been instrumental in shaping in our writing.  But if you're looking for a book to either extoll the virtues of forced care or to completely vilify it, you may need to hold back.  These are complicated issues and our goal is to talk a close look at involuntary treatment, figure out when it can be made kinder and gentler, and figure out if or where it fits in with psychiatry and/or the prevention of violence.

Friday, June 06, 2014

Help! My Patient Got Arrested. What Do I Do?

Today over on Clinical Psychiatry News I give advice to mental health practitioners about what to do when you need to make sure your patient is taken care of when he ends up in jail. This is never the kind of stuff they teach you in residency, so I end up fielding phone calls from friends and colleagues about it sometimes.

Hopefully you'll never have to deal with this, but if you do you'll know where to begin. Read the column here.

Saturday, May 31, 2014

And now for something warm and fuzzy!

Psychiatry these days --- I could do link after link and commentary after commentary about guns and violence and mass shootings and can we prevent all this?  But why?  Let's go for something sweet and warm and fuzzy and ducky today.  I hope you enjoy the video above.

Tuesday, May 27, 2014

Just a Phase?

Today's Shrink Rap post is located over on Clinical Psychiatry News.  "Distinguishing the killers among us" is a story I've written about before here on Shrink Rap, about a situation I dealt with in high school. 

 The timing seemed right to tell the story again. 

Thursday, May 22, 2014

Maryland work group on legislation regarding involuntary care needs PATIENT input!

On May 20th, I attended the Maryland Department of Health and Mental Hygiene (DHMH)'s first Outpatient Services Programs Workgroup, designated by Senate Bill 882/ House Bill 1267.  These were bills proposing legislation to bring outpatient commitment ("assisted" outpatient treatment - AOT) to Maryland and to look at the use of ACT (assertive community treatment) and other outpatient services in Maryland.  The meeting was the first of 8, and they are open to the public.

Since involuntary outpatient treatment is a controversial topic, it's no surprise that the room was full and all the stakeholders were represented.  I'm going to guess there were 120 people there, and I saw people from NAMI, TAC, the public defender's office, the psychiatric society and our diligent lobbyist.  One thing that surprised me was when one man announced that he was one of only three consumers there.  Really?  This is about legislation that might impact people with psychiatric disorders, shouldn't they come to have a say?  I spoke with this gentleman after and was told there was no transportation available to bring people them from their day programs.  But really, aren't there people out there who have been committed to hospitals, who might be concerned about this legislation, who have cars? I guess they'd need to get time off work, as I did.  I also think it's possible they didn't know about the meetings, so I'm posting this here.  I knew about it because I'm on the psychiatric society's legislative committee, and obviously another hundred or so other people knew about it, but if you know someone who might like to attend, please spread the word.  Please be aware that the meetings may be moved to a larger space. 

I hate the idea that stakeholders make these decisions for people -- some of whom are quite outspoken and organized -- without their input.  Those who've benefited from forced care need a voice. And those who've been harmed by forced care also need a voice.  If you have something to say, or you just want to listen to the process, these meetings are open to the public. 

Per Facebook:
DHMH to Convene Behavioral Health Integration Stakeholder Workgroup: Members of the public invited to participate

The workgroup will make recommendations on issues related to behavioral health, including statutory and regulatory changes to... See More

Monday, May 19, 2014

Can Medication Prevent Crime?

Ah, not here, not now, but over on Clinical Psychiatry News, ClinkShrink looks at the question of whether medications can prevent crime and she talks about a study in Sweden that was recently published in Lancet.  Let me redirect you over there:
 Can Medication Reduce Crime?

Sunday, May 18, 2014

The HIgh Cost of Forced Outpatient Care

I'm going to refer you to a long article in The Herald News,  Focus: Safety concerns prompt states to revisit involuntary commitment laws that address the mentally ill.  

Now I'd like to bring you to the end of the article where there is mention of the fact that President Obama has authorized $60 million to fund these programs.  If we divide that evenly between the states, it's about $1.2 million per state.  New York already has a program for involuntary outpatient commitment called Kendra's law.  The studies have shown that it has been successful in decreasing hospitalizations and incarceration.  The costs are calculated  per person "before" and "after" involuntary commitment, so the amount of money shelled out for each patient goes down when they've been put in the program.  What isn't reflected in the cost, is the overhead and infrastructure that New York State put in place to increase services.  I will point out to you that Kendra's law is mostly used in New York City, around Albany, and a few other hot spots, but not in the rest of the state.  And how much money has this successful program cost to implement in these populated parts of New York?  From the website of the NY Office of Mental Health:

Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment
Resources to Provide Court-Ordered Services

The Governor's budget for Fiscal Year 2005-2006 provides more than $32 million for operation of services in support of Kendra's Law. This appropriation continues State support of case management and other services aimed at keeping recipients in a treatment program, including psychiatric medication as required. Since Kendra's Law went into effect, Governor Pataki has also acted to expand access to case management and other key community-based mental health services that would be needed by individuals receiving court-ordered treatment, as well as many other individuals with severe mental illness who have less intensive, but still substantial, service needs. The Governor's budget for Fiscal Year 2005-2006 also provides more than $125 million in ongoing funding for such services. This "Enhanced Community Services" funding has been used to both improve and expand the capacity of the existing community-based mental health system and to strengthen the cohesiveness and coordination of that system. More specifically, Enhanced Community Services were designed to steer the New York State mental health system toward a more person-centered, recovery-oriented service delivery approach, and were targeted for the following purposes:
  • to expand case management, Assertive Community Treatment (ACT), and housing services to support community integration;
  • to develop Single Points of Access (SPOA) to better manage service access and utilization; and
  • to increase the availability of other services that enhance community participation and improve the engagement, quality of life, and satisfaction level of service recipients.
 Many states have involuntary commitment laws. Few of them implement them, as the Herald News article highlights.  It costs too much.  $60 million is not going to do it for a country of 300 million people.  And while we do know that the program reduces hospitalizations and incarcerations in this vulnerable group of very ill, high users of emergency mental health services, what we also know is that the recipients don't like it; satisfaction rates are low (---that statistic doesn't make the news, presumably because no one cares?)

Finally, the article ends by pointing out that involuntary outpatient commitment is not about forcing medications.  This is a common saying of those who support it, but when legislation was proposed in Maryland, the legislation included an order for a specific class of medications and procedures to make changes or contest it.  If a judge tells you that you have to take a medication or you can be brought by the police to a hospital for evaluation, how is this not forced medication? 

Friday, May 09, 2014

Tell Me About Sweden

I've been delving into a recently published study from Sweden that was mentioned here in the Wall Street Journal. The study looked at the effects of psychiatric medication compliance on violent crime. It's interesting and intriguing but I have to say I'm struggling to see how or if this may be applicable to people in the United States. Thus, this blog post. I know from Google analytics that we've had almost 5000 page views from readers in Sweden this month alone. I know that many of our blog readers are patients. Please, tell me about your mental health care system. From the paper I know that your legal system is very different from ours: you essentially have no insanity defense. It appears that the only time mental state issues come into consideration is at sentencing. This means we really can't know how many of those violent crimes actually were due to psychiatric symptoms.

But beyond that fact, I'd like to know how the community response to mental health issues may be different and about differences in the system of care.

Some questions, off the top of my head:
-Are there mobile treatment teams that respond on site to patients in crisis?
-What is the emergency evaluation process, how long does it take, does it work?
-If there is an emergency response, how often do patients get taken to a hospital vs some other alternative?
-What are the involuntary medication laws like? How often is this pursued? How often ordered vs not?
-Are outpatient services integrated with substance abuse treatment and medical care?
-How long does it take to get into outpatient treatment?
-Is there legal enforcement for outpatient treatment? What does it look like? How often is it sought?
-Are there pretrial diversion programs for mentally ill people who get arrested and charged with crimes?
-Any thing else you'd like to tell me?

Don't be limited by my questions. I have trouble believing that a single intervention like medication should have such a significant impact on crime. Disclaimer: this is probably going to be my next Clinical Psychiatry News column, so you may be quoted.

Wednesday, May 07, 2014

Privacy versus Necessary Communications

Greetings from New York.  All the Shrink Rappers have been enjoying the APA meetings these past few days.  

Today's post is located over on the Clinical Psychiatry News website: Legislation's privacy exceptions of psychiatric patients are concerning.  Do surf over and read the post there

Wednesday, April 23, 2014

No Easy Answers

Today's post is brought to you by Steve Lopez of the LA Times and is located over on Pete Earley's blog.  You can click HERE to read the touching story of Nathanial Ayers, a talented musician who suffers from schizophrenia and does not want to take medication for his condition.  On his third court appearance, a judge appointed a relative as conservator for Mr. Ayers so that medications can be given.  It sounds, from the article, like Mr. Ayers had intolerable side effects to an older anti-psychotic medication and has never been willing to try the newer, atypical anti-psychotics which have more favorable side effect profiles --unless, of course, you're the person having the side effects, in which case the "profile" may not matter.  Please read the article over on Mr. Earley's blog, then come back here to read about my thoughts.

So I'm hoping that the story has a good outcome, and here are a number of things that may happen here.  I go from best possible outcome to worse possible outcome, and feel free to shuffle the order on the shades of gray:

  • Best:  Mr. Ayers takes the medication, it works, his symptoms resolve, he feels better emotionally, and he is able to function better, and he has no side effects and decides he wants to continue it.  This would be the happy ending we all want to hear.
  • Mr. Ayers takes the medication with resolution of his symptoms, improved functioning, and no side effects, and no appearance of metabolic syndrome, but he does not recognize that he is doing better without the medications and wants to go off but the court insists he continue.
  • Not bad: Mr. Ayers takes the medication and it works with resolution of his symptoms and improved functioning, but he has side effects.  He decides the improvement is worth the side effects and chooses to continue taking the medication.
  • Mr. Ayers takes the medications and it works, but he has intolerable side effects and needs to go off it.
  • Mr. Ayers takes the medication and it works, but he has  side effects and the courts make him continue with a medication that makes him feel bad 
  • Mr. Ayers takes the medications and it doesn't work, so he stops taking it.
  • Mr. Ayers takes the medications and it doesn't work, but the court insists he continue taking it.
  • Mr. Ayers takes the medications and it doesn't work, and he has  side effects, and the court insists he continue taking it.
  • Mr. Ayers takes the medications and it doesn't work, and he has intolerable side effects, and the court insists he continue taking them and then has a stoke or heart attack or diabetes which may have been brought on by the metabolic effects of the ineffective, intolerable medication that the court made him take.  
  • The medication works and the patient stops it and has a tragic outcome, either for himself or for others.  
Unfortunately, what makes the scenario even harder, is that the medication may partially work or be  somewhat effective -- so perhaps a given patient is less irritable or combative, which makes it easier to manage him or her -- but still hears distressing voices or experiences intolerable emotions.  We don't know exactly how long to wait, how high a dose to give, or how many medications, alone or in combination, we need to try before we're sure there  is no adequate treatment.  Also, the tolerability of side effects and the acceptibility of risk are things that may be difficult for one person to make for another.  

This is a long way of saying that unless the patient has a positive response that he appreciates, the issue is not a simple one; it can be complex and nuanced in a way that many of the parties may not appreciate.  If our medications worked more reliably, and did not have side effects and pose the risks (risk, not certainty) of decreasing both the quality and quantity of life, then forced medication would not be such a difficult option.  But the issues of limited efficacy and tolerability exist before you even begin to address the civil rights of a person to decide their own care.

I hope we'll hear about the outcome from Mr. Lopez, and I do hope Mr. Ayers has a good response and decides, on his own, that he'd like to continue the medication.  And if it doesn't work, I certainly hope the court does not force him to take an ineffective agent that he does not want.  In our "meds are good" society, it's not that unusual for people to be on medications long after we've lost track of what it was we trying to target with them.

On a different note, I spent my day with a police officer today who does crisis intervention.  As we stated the day, he received an email from a patient he had petitioned to the hospital 2 years ago, thanking him for forcing her to get care and for saving her life.  It was my feel-good story for the day.