Tuesday, January 30, 2007

My Three Shrinks Podcast 8: Positively Lost


[7] . . . [8] . . . [9] . . . [All]

This podcast is a continuation from our #7 podcast, in front of Dinah's fireside studio (complete with the sound of an actual fire popping). I decided to leave those sounds in, but I did edit out Click's occasional cough (she's all better now).


January 30, 2007:
Topics include:
Next week: Biochemical effects of chocolate on mood.
The musical snippet used in last week's podcast came from the Boomtown Rats' "House on Fire", from their 1994 album, Great Songs of Indifference.


Find show notes with links at:
http://psychiatrist-blog.blogspot.com/2007/01/my-three-shrinks-podcast-8-positively.html
This podcast is available on iTunes. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Monday, January 29, 2007

Feline Felons Released to Home Detention


Anybody who knows me will know I can't resist a story like this. It combines cats and prisoners, two of my favorite topics. (If you could figure out a way to work chocolate in there we could have a trifecta.) Here's the story from CBS news:

Vermont Prison Paroles Cats

Apparently the women in this particular prison took to caring for the various strays that took up residence there. It's not clear what actually precipitated the decision to find free society homes for these cats, but they've gradually been giving them away (after appropriate spaying or neutering).

When I first read this story it reminded my of my long-ago post Paws For Reflection where I blogged about my favorite drug detection dogs. (Can you believe our blog was only two weeks old back then?) These cats don't have any institutional responsibilities other than to be loved and adored by the prisoners. Rough life. Don't they know prisoners aren't supposed to be cuddled...er, coddled...even if they do have fur?

My other thought was: "Gee, don't they know that 'cruelty to animals' is one of the diagnostic criteria for antisocial personality disorder?" And indeed, one poor animal did get his fur burned off by an inmate. (What are the chances that inmate was given a written infraction for that?)

And so they are off to home detention. I'll give them the traditional prison send-off:

"Be safe out there."

Friday, January 26, 2007

My Planned Nervous Breakdown


Now I'm done thinking about the whole issue of who should get care, how, where, and by whom. Tired of ranting.

Okay, so I got this e-mail from ClinkShrink. She says that if I need to be psychiatrically hospitalized, The Retreat is out for me, apparently Rock Climbing is part of the package. As part of my blurred blog/real life dimensional problems, I tried wall climbing a few months back after Shiny Happy Person (of Trick-Cycling for Beginners) posted about the wonder of it. I couldn't get to the first foot-hold. I stood there, unable to lift myself, wondering why I'd want to do this anyway. My twelve-year-old daughter, who was kind enough to accompany me, scrambled to the top. Repeatedly. Clink ended her email by offering to be my roommate if I needed inpatient care. How sweet to have such a devoted friend. And if that doesn't make me feel fuzzy enough, Roy sent me Frank Zappa and Captain Beefheart performing Muffin Man. How good does life get?

So, I wasn't planning on The Retreat, at $1700/day, or any other inpatient psychiatric facility, for that matter. I realize, of course, that there are some aspects of life that one doesn't plan and that aren't under our control, but there are a limited number of things I can worry about, so I was going to leave this off the list. ClinkShrink got me thinking though: If I do ever need an intensive level of psychiatric care, what am I going to do.

I've decided to plan my own, luxury-laden, cost effective nervous breakdown:

I'd much sooner check into a nice hotel at $?400/day (+room service, with chocolate turndown service) and have daily outpatient sessions with a psychiatrist, thereby wasting resources by using a psychiatrist when a cheaper psychotherapist might do or, if I needed meds, efficiently combining my psychotherapy with med management which actually would be saving resources.

Financially, if we could keep me from shopping during this endeavor, it could be both more luxurious and much cheaper than The Retreat, figure roughly $550/day-- not bad for a feather bed, color tv, private bath, feather bed, turn down chocolates, and daily 50 minute sessions with a psychiatrist rather then a fresh-out-of-school social worker or any other mental health care professional assigned to me by a hospital unit in a setting where I wouldn't have any choice to have a shrink with a certain type of training (I want a blogging one who can identify...) or worry about things such as patient-doctor chemistry-- a doc I'd like and feel comfortable talking to.

Okay, okay, my $550/day rate doesn't count food, but:
I could probably be happy even with much cheaper Chinese delivery as opposed to expensive room service menu and many nice hotels are less than $40/day, the Ritz Carlton in Philly has (I think) a $200/night for the weekend special rate, (though the eggs benedict via room service is hefty) and for an extra fee, they'll come draw you a bubble bath with candles and champagne. We won't talk about how I know these things, but trust me, there are better places to hang out if you're looking for R & R and getting away from it all, then in a psychiatric hospital.

It might be hard to pair the hotel setting with the top-notch shrink physically, especially since I was thinking of having my breakdown at the Eastern Shore Marriott resort (good rates, beautiful rooms & setting, but no psychiatrists out there), or to find someone with 5 open hours a week waiting to be filled.

I once knew someone who called me because his wife was in the midst of a horrible, clearly in need of hospitalization, depressive episode, and I arranged for her to talk with and be admitted to Top Mood Doc's Unit in Great Hospital in Baltimore (Thanks to Fat Doctor for teaching me how to name people & places). They were even going to meet her at her car and walk her up. Ah, instead the couple hired a private duty round-the-clock nurse and took her to a private psychiatrist.

Wonder if I throw the private duty nurse into the hotel scenario, if that would still exceed the $1700/day cost?

Okay, tongue-in-cheek, of course. People in need of hospitalization for a mood disorder are not able to enjoy or benefit from eggs benedict, bubble baths, or feather beds, and my post here isn't meant to demean anyone's suffering. If, however, you're overwhelmed, stressed out, on the edge, but not actually in the midst of a major depressive episode, there are better and cheaper places to regain your composure then on a psychiatric unit, any psychiatric unit. But if I do go, I want Clink to be my roommate. Hoping that sharing a room with husband, children and Max doesn't bother her.

And now for something completely different...


...a blog with three topics.

Headlines in the News...

1. Read this headline carefully... "Teen accused of fondling girl to get psychiatric evaluation". If this is what it takes to get a psych eval nowadays, then we truly need universal health care ASAP!!

2. "CCHR criticises psychiatry" ... this is "news"?

3. "Iguana's stubborn erection to get the chop" ... this is why we are taught in medical school to avoid trazodone in iguanas.

Still Stewing

[ranting by dinah]

I'm still stewing about ClinkShrink's comments about all those Worried Well folks out there. You know, the hoards taking up luxury hospital beds to get their adjustment disorders fixed, or using up the few precious resources available for psychotherapy by talking about day-to-day stuff. She made a comment on our podcast (oops, I didn't listen to it, but I might just to stew some more over this comment) about how if physicians don't ration psychiatric care, it will be done for us, it's coming, it's inevitable. Personally, I think Clink's been drinking the Kool-Aid.

I don't have "a" patient with an Axis One disorder whose symptoms resolved and who still comes but talks about day-to-day stuff. I have many. None, for the record, drink coffee with me.

Here's how psychiatric illness goes:

A patient comes in with complaints. Seeing me takes time, an outlay of some money, and hassling with your insurance company (no secretary, no insurance participation). No one, and I mean no one in over a decade of private practice, has ever walked in the door saying "I'm coming to talk about day-to-day stuff." No one has ever come to be self-actualized. Almost everyone cries. Everyone is in some state of distress and the vast majority of people I see are already on medications or will be by the time they've seen me a few times. Some people aren't, and maybe they want to work on something concrete-- something like a tormenting marriage, or the fact that they are pre-occupied to the point of great angst over a former lover stuck in their head (sometimes for decades) or an ongoing or acute stress in their lives. It's okay if these folks get help even if they don't have a major mental illness?

So, the majority, the gang we all agree deserve care, those Axis I folks, they take some meds, they talk (generally about the day-to-day stuff going on in their lives) and most of them get better, soon. Some still come for a while, until they're sure that the better holds (it doesn't always), or because they don't get all the way better and the symptoms fluctuate, or because the talking lends some comfort in a life where things are difficult. Carrie, summed it up when she said about meeting with her psychiatrist when she's not in acute distess, " If I do not continue to work with him in the way that I am at present, then I believe that I tend to fall very quickly back into my own depressions." I couldn't have put it any better.

This is the deal, the newsflash: in psychotherapy, everyone talks about the day-to-day stuff going on in their lives . They talk about what's happened since they came last. They highlight the trouble spots. Some relate current events to past patterns. Some are more interested than others in talking about their childhoods. Sometimes, people talk about the routine-- I've commented before on a (confabulated, of course) patient who talks about the price of beef at various stores. That patient is on 4 psychotropic meds having tried many others, a couple of hospitalizations, and the last episode of illness lasted many months with many, many awful symptoms. If talking about the price of beef helps, that's fine by me. And trust me, if you met her, you wouldn't for a moment question her right to access psychiatric care.

Why should suffering be valid for discussion only if your distress can be boxed into a Chinese-menu DSM box of symptoms? Why is should it be okay to access care (where you'll talk about day-to-day stuff) if you have a mental illness, but not if you're just miserably suffering without a disorder as designated by some committee? And if you feel that talking is helpful, or perhaps prevents relapse (and why is that??), then why should it only be valid to come for therapy if you're hurting at this very moment? What if you were hurting yesterday or might hurt tomorrow, or just want to tell the doc you're doing better?

And to those who've suggested (or demanded) that patients should see non-psychiatrist mental health workers for psychotherapy and psychiatrists only for meds: Why? What if the psychiatrist wants to see patients for psychotherapy? What if the patient wants to see a psychiatrist for psychotherapy? I'm not saying everyone psychiatrist must do psychotherapy, nor am I saying that someone who wants to see a psychologist or social worker shouldn't. There are plenty of psychiatrists who are still interested in psychotherapy and some of us who don't find seeing four patients an hour to write a script based on a minimal amount of information particularly fulfilling as the only aspect to a career. I'll do a post later on split treatment in public settings -- I tend to blog from my private practice hat, but I work in a public clinic as well.

There are plenty of patients out there with severe mental illnesses who don't keep appointments and therefore waste resources. There are many who refuse to take the prescribed medications, whose own behavior results in repeated hospitalizations at great cost to society. They are the very ill, certainly the rightful recipients of our care, but we don't have an efficient system to define and weed out exactly how much care who should get from which professional and what it's okay for any given patient to talk about.

While I don't believe that society (meaning government-run clinics, medicare/medicaid) owes every person who wants it unlimited psychotherapy with a psychiatrist, I do believe that the definition of Patient-hood lies with the patient. And I don't share Clink's pessimism that this will lead to an overload on the private insurance system and more regulation is to come: Managed Care has been a dismal failure and the pendulum has already started to swing the other way.

Clink (who has posted simultaneously, see No Retreat) seems to think it's one pot of money, and if one guy pays his way for top-notch care, another guy suffers. We have universal education (sort of, think of all those children left behind), yet many people opt out for private or religious education, paying out-of-pocket. That, I believe, is similar to getting care at any private venue that allows one to pick and choose, to ask for what on perceives to be The Best.
Okay, I'm done ranting.

Roy, where's the new picture of our feet?

Thursday, January 25, 2007

No Retreat



I've never written a post to respond to one of my own posts before, but I think this time I have to. I have gotten enough "Clink is a heartless bastard" comments that I need to write, for the last time, that my post on the Retreat was a criticism of the service, not the patients. It got warped into an animated and a bit of an angry discussion about who I thought was or was not deserving of treatment---as if I my opinion about that actually mattered.

It's no revelation to state that America has a three-tiered healthcare caste system: the have-nots, the have-somethings (with insurance) and the boutique set. I work with the have-nots. My patients are poor. I don't mean poor in a "don't-have-insurance" sort of way. I mean poor in a "My family died in a house fire because they were using candles for heat and light" kind of way. The kind of poor who come in psychotic from the streets after living over sidewalk grates in the wintertime. The kind of poor who will die fast unless they get locked up.

So when I see a web site like the Retreat it's like getting a punch right between the old values. It's a visceral reaction, an "oh...my...gawd" kind of feeling that can't even come close to comparing with what my patients will never have. It's a sense that the cosmic balance of justice has gone far far out of whack and that we are in for an upheaval of our own making if we don't do something proactive to address the problem.

I am not stating that the boutique patients are undeserving of care. I am saying that we as a society need to make sure that all who need healthcare receive it. We as a society need to make these decisions. They cannot be left to bureaucrats or businessmen, or even solely to doctors and patients. We have all created this system and we must resolve it. Boutique medicine is not the solution.

To do this we will have to answer difficult questions about where to put our resources and how far to go with them. We will have to weigh the pros and cons of a fifty minute therapy session for non-psychotic patients versus two med check appointments for psychotic folks. People who are receiving treatment now may have to give a little to make room for those who are receiving none. I don't think that's too much to ask.

[Addendum: While I was working on this post I read on CNN that all the current Democratic candidates are in favor of universal healthcare coverage. A national health system is on the way. Hopefully Shrink Rap's posts will help us prepare for this by leading some discussion.]

My Three Shrinks Podcast 7: Fireside Chat


[6] . . . [7] . . . [8] . . . [All]


Blame Roy on the delay in getting this podcast out. We strive to get these out on Sundays, but life just gets in the way sometimes. We recorded this on Sunday, Jan 21, in front of Dinah's fireside studio, when we had our first snow of the season (not even an inch). Go to the bottom of these Show Notes for a picture of us in front of the fire (the crackles and pops you hear in the audio are from the fire).
Roy (our podcast producer) has added a new "feature" where the music which is played as we transition from one carefully planned subject to the next will change from week to week. Feel free to figure out where each week's song snippet comes from. The first one to figure it out will receive the dubious distinction of a link to their blog or site in the following week's Show Notes. (Extra points if you can find some connection between the song and a topic from the podcast.)


January 24, 2007:
Topics include:
  • Dinah's post on the "Well-Worried Well" provokes dissension amongst the Shrink Rappers. Are folks who go to high-end hospital units, such as The Retreat at Sheppard Pratt, just the worried well, or are they "rich people with mental illness"?
  • Paying for Psychotherapy: "That's the problem with reimbursement for psychotherapy. How do you decide what is and isn't valid psychotherapy?"
  • BusinessWeek, 1/29/07: "Held Hostage by Health Care", by Michelle Conlin. Article about people who stay in jobs they hate due to fear of losing their health insurance coverage.
  • Movie: Idiocracy [IMDB link] from Roy's post of YouTube video, Hospital of the Future.
  • National health care system.

Find show notes with links at:
http://psychiatrist-blog.blogspot.com/2007/01/my-three-shrinks-podcast-7-fireside.html
This podcast is available on iTunes. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.


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Tuesday, January 23, 2007

Dying For Some Data

I want to thank Steve of OmniBrain for posting this information on his blog; the Bureau of Justice Statistics just released the data this month and he saw the press release.

The BJS published all-cause mortality data on American prisoners from 2001 to 2004.This is the first comprehensive report of mortality since the Death in Custody Report Act was established to set up this surveillance system. This is what they found:

Almost all (89%) of deaths were due to medical conditions and these medical conditions were present prior to incarceration. Almost all inmates had been seen by a physician and were in treatment at the time of their deaths. Almost half the deaths between 2001 to 2004 happened in five state systems: California, Florida, New York, Texas and Pennsylvania. The states with the lowest mortality rates were: Vermont, Alaska, Iowa, North Dakota and Utah.

The mortality rate for American prisoners was 19% lower than for adults in free society. For African Americans the prison mortality rate was 57% lower than free society. Prison death rates increased with age and were highest in inmates 45 years old and older. The average annual suicide rate was 15 per 100,000 (essentially unchanged over the past 20 years).

AgeResidentPrisoner
25-3410564
35-44203179
45-54430560
55-649521,481

Here's the age-matched mortality rate comparison between prisoners and state residents. Mortality rates invert between the two after age 45, when mortality for prisoners is higher than among residents.

There's a lot to chew on here. This report does not include mortality data for jails, which apparently is going to be reported separately. The full report can be found here. I'm sure you were dying to know this.

Monday, January 22, 2007

This Is Our 300th Post!

Some bloggers announce their anniversaries. We'll do that, too, I've no doubt.

Since April, we've been posting, podcasting, meeting, texting, emailing, dining at Roys (of the restaurant chain), photographing our feet (how nuts is that?), blogging about jails, inmates, psychotherapy, drugs, neurotransmitters, patients, doctors, both, neither, brain anatomy, floor boards, sleepless nights, ducks, our fellow blog-o-land friends, Iowa, The New York Times, The Ravens, movies, TV shows, anything anyhow that we could make sound in any way Shrinky or not.

This is our 300th Post!

Sunday, January 21, 2007

FDA Drugs: November 2006

2007: Mar | Feb | Jan . . . 2006: Dec | Nov | Oct | Sep

Just a quick list of psychiatry-relevant FDA and related notices...
  • More Ambien (zolpidem) generics (and here) get tentative approval. Sanofi's patent expired on Oct 21, 2006, but they triggered an automatic 6-month extension by applying for pediatric use. We should start hearing about generic Ambien around April or May. The first approved generic manufacturer gets an automatic 6-month exclusivity before the flood gates open up, and other manufacturers can get into the game. There are about a dozen manufacturers all lined up for tentative approval.

  • Phase I results promising for NGX426. NGX424 gets coverted in the body to tezampanel, an AMPA/kainate receptor antagonist, which makes it a non-narcotic pain medicine. The company, TorreyPines, seems to be looking at indications for migraines and neuropathic pain, though this class of drug may be useful on epilepsy and anxiety, as well.

  • Drugs to turn on specific genes. This is one of the new holy grails. As described in the linked PNAS article, using RNA interference techniques, you make a little piece of double-stranded RNA (dsRNA) that is designed to bind to a specific gene, say, the gene that contains the instructions for making amyloid precursor protein (APP), which is involved in causing Alzheimer's dementia, or maybe the gene that codes for a particular variant of the CETP protein, which has been associated with increased longevity. According the article, sometimes this technique will silence a gene, and sometimes it will crank up the volume. Drugs of the future would be used to selectively turn on, off, up, down genes, like fiddling with 100,000 dials on a huge mixing board, trying to get just the right mix. A fascinating, but scary, proposition.

  • Mirapex (pramipexole) approved (label .pdf) for Restless Legs Syndrome. This is old news now, thanks to the marketing blitz on this indication.

  • Generic Zyprexa (olanzapine) gets tentative approval. There are now 5 companies with approved versions of generic Zyprexa, waiting to launch when either Lilly's patent expires (2011) or someone successfully challenges their patent application (now in process).

  • Rimonabant (brands Acomplia or Zimulti) approved in Mexico. The sexy new diet drug is already approved in Europe, and is now on our shores. Rimonabant is a CB1 cannibinoid receptor antagonist, so it will also block the munchies from smoking marijuana. Sanofi Aventis has already submitted a new drug application to the U.S. FDA, followed by a resubmission in October.

  • Seroquel marketing warning letter. AstraZeneca received an FDA letter warning that they violated the rules by underemphasizing the risk of diabetes with Seroquel in a piece of marketing material. They also failed to note some other risks.

  • Warning: Tamiflu side effects - delirium, self-injury. Roche and FDA sent out notification letters warning of reports about self-injury and delirium occurring in people, especially children, who have the flu and take Tamiflu. They note that these reactions may also occur from the flu itself.

  • Warning: Methadone side effects - cardiac, breathing, death. FDA put out a public health advisory warning of "reports of death and life-threatening adverse events such as respiratory depression and cardiac arrhythmias in patients receiving methadone. These adverse events are the possible result of unintentional methadone overdoses, drug interactions, and methadone's cardiac toxicities (QT prolongation and Torsades de Pointes)."
Search the FDA's "Orange Book" for more drug data.

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Hospital of the Future

In response to Clink's recent post about posh inpatient psychiatric units and Dinah's previous post about diagnosing mental illness (vs worried well), here is a vision of how we will diagnose medical problems, such as hallucinations, in 2505 (hint: the anal probe is critical). . .

Saturday, January 20, 2007

Pay In Advance To Retreat


While we're on the topic of the Worried Well, you might be interested in seeing what kind of inpatient care the worried well can get by paying $1700 per day out of pocket (that would be $34,000 up front for the first 20 days of inpatient diagnostic assessment):


Private rooms include a bath, television with cable access, bedside telephones and internet connection. (Do they have a turn-down service with chocolates on the pillows?) It is for the longterm (months) treatment of mood disorders, anxiety disorders and "disabling adjustment disorders". (Translation: if you're paying enough we won't stigmatize you by diagnosing you with a personality disorder.) In addition to standard treatment modalities they also use "Eastern movement and meditative practices" (I wonder how you give informed consent for treatment for an unproven therapy?).

Now, as long as it's not being paid for by my tax money or supported by my insurance premiums then I suppose I can't legitimately beef about this. But it's still mind-boggling.
================
[Edit: see also No Retreat, Still Stewing, and My Planned Nervous Breakdown for more on this. Also, listen to our podcast.]

To Iowa: I'm Sorry


I feel like I need to apologize because Maryland just stole something from you. I think what we did rises to the level of Indianapolis whisking away our former football team, the Colts, in the middle of the night.

I'm referring to the announcement I saw in today's paper about our new head of public safety, Gary Maynard. I have to say, this looks like one terrific choice by our new governer. Mr. Maynard is someone who worked his way up through the ranks within the correctional system. He has been a warden, an assistant commissioner, and has also run prison systems in South Carolina and Iowa. He is currently the head of the national correctional officers' professional organization, the American Correctional Association (also based in Maryland). This is one of the organizations that sets standards for accreditation of correctional facilities across the country.

But the thing that tickles me most: He's a psychologist. The person ultimately responsible for reforming Maryland's criminals actually has clinical training! This is the first time in recent memory we've had someone in charge with clinical skills. (Usually we get a lawyer with some administrative experience who happens to be a friend of the governor.) This is a very very good sign.

I know that our gain is Iowa's loss. From the article it sounded like they weren't expecting him to leave. Thus, the apology. I hope we can still be friends. (And I hope I can still keep my University of Okoboji t-shirt.)

Friday, January 19, 2007

The Well-Worried Well


Psychiatric and psychological treatments are used to address a number of issues including, but perhaps not limited to: the symptoms of designated syndromes of mental illness (for example, schizophrenia, affective disorders, anxiety disorders, attentional problems, personality disorders), the behavioral consequences of symptoms of psychiatric disorders (such as crawling under the covers while depressed, promiscuity while manic, homicide while delusional), primary behavioral problems ( such as substance abuse, gambling), maladaptive patterns that may arise outside of a mental illness (Why do I always end up with creeps?), dissatisfaction with life circumstances (I haven't lived up to my potential), difficulties coping with life stressors which may or may not precipitate a psychiatric illness and sometimes are the focus of treatment even in the absence of illness (grief, adjustment disorders), or a desire to gain insight and understanding of one's self as a goal of its own ("The unexamined life is not worth living." Thank you, Socrates). That was a really long sentence. In short, and to use the lingo of my former chairman, Psychiatry looks at issues pertaining to mental life and behavior.

If you hang around long enough, the term Worried Well gets thrown about. It refers, I think, to those folks using psychiatric treatment to broaden their insight, to maximize their functioning (so why am I still driving a cab when I have a graduate degree?), to lead richer lives. It may refer to people suffering from Anxiety Disorders, rather than the more "serious" illnesses such as schizophrenia or bipolar disorder It refers to the stereotype of the neurotic, sometimes Jewish, New York, Woody Allen characters who obsess and worry --though I will point out that Woody makes criteria for many diagnoses very quickly. It sometimes refers to those suffering from Major Depression who should just pull themselves up by those blessed boot straps. Actually, I'm not really sure who exactly those Worried Well are.

The Worried Well is a term used, even by or especially by, psychiatrists with a bit of disdain, especially by psychiatrists who treat severe, chronic, and persistent mental illnesses. The broader question embedded in the subtext of the term begs: Who Warrants Care? How do we allocate our resources? What is worthy of the psychiatrist's time and attention, and who should foot the cost?

Most of the people who come into my office arrive while suffering. Suffering, it seems to me, warrants care, even though I'm occasionally left to say, "You don't have a mental illness." Suffering is sometimes just a part of life and life is often hard. Psychotherapy often helps, for reasons which remain a bit vague to me, sometimes medicine even helps in the absence of a mental illness (oh for a good night's sleep, or something to help that post-9/11 gotta-get-on-a-plane nervousness), but there are those who feel that psychiatric resources--especially those paid for by a third party-- should be limited to those with major mental illnesses.

It's a nice idea, but the lines get blurry. The more common scenario is that someone arrives in the midst of an episode of mental illness. They get better, usually fairly quickly. No longer in the throes of acute, intense, and miserable symptoms, the patient often continues to come on some regular basis. They still need their medications monitored, but it's more than that. Sometimes patients are afraid to stop coming-- fearful their symptoms will recur. Often, they say they feel better after a session. Many have periodic mini-flares in their symptoms-- normal variations in mood perhaps because moods do afterall vary some, but once someone's had an awful episode, they can get very sensitive to even little changes. Sometimes, it's simply hard stuff to articulate. And honestly, I've followed a number of people who show up regularly to talk about the stuff-of-life, who come despite a lack of symptoms, who at some point later on develop raging symptoms. Sometimes it's about alleviating symptoms, sometimes it's about preventing relapse, sometimes it's about holding on for the ride. Sometimes, I don't even know what it's about.

Does it need to be articulated? We take children to the pediatrician when their ears hurt. We don't say, oh it's probably viral, I won't waste the doc's precious time. How many unbroken arms get x-rayed, how many normal brains get scanned in patients with unremarkable neuro exams? And what about the zillions of screening mammograms and then diagnostic biopsies on all those women who
will never get breast cancer? Or the all those PSA's for men over 50? Many conditions get better without treatment, but we don't begrudge anyone a medical evaluation to be on the safe side.

I sometimes (-not a lot, the folks who wander into a psychiatrist's office are a self-selected crew) say "You don't have a mental illness." I've not yet said to anyone who's walked in while suffering, "Don't come for psychotherapy."

P.S. If you have the answer, by all means, comment!

Thursday, January 18, 2007

Ritalin or Abilify for I.V. Amphetamine Dependence

Here's an interesting article from Finland in the American Journal of Psychiatry [PubMed] looking at potential treatments for intravenous amphetamine or methamphetamine (speed or ice) dependence.

Since amphetamines are dopamine agonists, the thinking was to replace it with another dopamine agonist (such as methylphenidate/Ritalin) or a partial agonist (such as aripiprazole/Abilify), in much the same was heroin is replaced by methadone or buprenorphine.

"While methadone and buprenorphine have proven
highly effective substitute medications for opioid depen-
dence (3), no pharmacological treatment has been found
thus far for amphetamine dependence (4). Partial dopa-
mine agonists such as aripiprazole are considered to be
promising medications for addiction, since they are sup-
posed to balance and restore normal function of the me-
solimbic dopamine system (5). Observational studies,
nonrandomized trials, and one randomized study without
a placebo arm have suggested that oral dextroamphet-
amine may be used to replace illicit intravenous amphet-
amine use (4), which suggests that oral methylphenidate
(dopamine reuptake inhibitor) might also be used to sub-
stitute for intravenous amphetamine use. On the basis of
this information, we aimed to compare the effectiveness
of aripiprazole, methylphenidate, and placebo in the
treatment of amphetamine dependence using urinalysis
as an objective measure of primary outcome."

What was interesting about this study, and why they stopped it prematurely, was that they discovered that the Abilify increased the amphetamine abuse. At the end of the double-blind, placebo-controlled study (n=53), looking only at positive urine samples to indicate relapse, 79% of the placebo group relapsed, compared with 46% of the methylphenidate group (54mg/day), and 100% of the aripiprazole group (15mg/day).

"Our results indicate that methylphenidate treatment is
associated with a statistically significant reduction in in-
travenous amphetamine use when compared with pla-
cebo, providing the first controlled evidence of an effective
pharmacological treatment for amphetamine depen-
dence. On the contrary, aripiprazole treatment was associ-
ated with a higher proportion of amphetamine-positive
urine samples than placebo.

While aripiprazole (in amphetamine dependence) and
naltrexone (in opioid dependence) may be good treat-
ments in theory, it seems that effective pharmacological
maintenance treatments for intravenous drug depen-
dence are substances that induce at least some euphoria,
such as methadone and buprenorphine in opioid depen-
dence (3), or methylphenidate in amphetamine depen-
dence. Slow-release methylphenidate may be superior to
usual short-acting formulation, since the patient may start
experiencing cravings for amphetamine as soon as the ef-
fect of the substitute drug disappears. It is likely that meth-
ylphenidate should be dispensed mostly on a daily basis
under supervision because of its abuse potential. Ari-
piprazole (15 mg/day) was not effective in this trial (an ab-
stinence facilitation trial), but we cannot draw any conclu-
sions on its potential efficacy in a relapse prevention study
among detoxified patients.

These results show that amphetamine use began to de-
crease substantially as a function of time after 10 weeks of
methylphenidate treatment reaching statistical signifi-
cance at 18 weeks, which indicates that it may take an
even longer period of time than 20 weeks to achieve full
benefit from this treatment."


So, they suggest that, for treatment purposes, Ritalin:amphetamine::Methadone:heroin, and further suggest daily, administered dosing to reduce abuse, perhaps earning weekend take-homes. Hmm, that doesn't sound too promising, except for maybe court-ordered folks who want to stay out of jail.

But the real take-home message, for me, is to consider avoiding Abilify in pts with psychosis who have a history of comorbid amphetamine abuse.



Amphetamine molecule
Amphetamine molecule. Note the phenyl ring on left, Nitrogen on right, and 2 carbons (ethyl) in middle. The squiggly is where a chemical group would be added to change the type of amphetamine compound.

Methylphenidate molecule
Methylphenidate/Ritalin molecule. Note instead of the N-amino group on the right, there is now a pyridine ring (with the N). That makes it less potent.



Norepinephine molecule
Norepinephrine molecule. Note the common phenyl ring on left, N-amino group on right, and 2-carbons (ethyl) in the middle.

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Tuesday, January 16, 2007

MythBusters


I'm writing to comment on an opinion piece published recently in the New York Times entitled "Mentally Ill, Behind Bars". I felt it was necessary to post about this because it was another story where people in the lay public would accept it as knee-jerk truth when in fact it seems to be repeating another correctional myth.

Mr. Harcourt, a professor of law and criminology, begins his piece by presenting a very familiar graph. The graph shows the number of people hospitalized in psychiatric facilities versus the number of people incarcerated in jails and prisons. The number of patients drops as the number of inmates rises over the years. Well and good, we've all seen that before. What concerns me is the fact that a full professor at an American university does not appear to appreciate the difference between correlation and causation.

Of course the number of psychiatric inpatients have fallen over the last fifty years. Prior to that we had no real treatments for mental illness. Thorazine wasn't invented until 1954. Tricyclic antidepressants were invented in the 1950's. Lithium was still experimental in the early 1970's. The majority of advances in psychopharmacology have taken place in the last thirty years, coincident with the rise in incarceration. (And I emphasize the term 'coincident'.) In addition to advances in pharmacology we also have more non-pharmacologic interventions. We have programs that act as therapeutic alternatives to hospitalization. We have partial hospitalization programs and assertive community outreach or mobile treatment programs. We have forensic pretrail diversion and alternative sentencing programs for forensic patients.

What Mr. Harcourt fails to mention is that there has been no increase in the relative number of people with mental illnesses in correctional systems. The absolute numbers have increased, but not the proportions. There is an increase in absolute numbers of mentally ill prisoners because the prison population as a whole has increased.

But the following quote is where he really takes a leap. More than one, actually:

But the graph poses a number of troubling questions: Why did we diagnose deviance in such radically different ways over the course of the 20th century? Do we need to be imprisoning at such high rates, or were we right, 50 years ago, to hospitalize instead? Why were so many women hospitalized? Why have they been replaced by young black men? Have both prisons and mental hospitals included large numbers of unnecessarily incarcerated individuals?
Wow, so many conclusions, so little data! There's nothing in the graph whatsoever that would suggest that there has been a change in how psychiatrists make diagnoses. And it's odd to see a psychiatric inpatient referred to as an "unnecessarily incarcerated individual". They aren't incarcerated at all. The demographics are different in hospitals versus prisons because they are different populations.

One could also draw a correlation between the increase in incarceration and the rise in, say, prescriptions for antibiotics or the number of people travelling in commercial airliners. But you'd never hear anyone suggest that we are only locking people up because the airlines are overbooked. But the biggest thing that bothers me about the transinstitutionalization theory is that it's based on the premise that all psychiatric inpatients are potential criminals who would be in jail but for their hospitalization. This just flies in the face of reality. The majority of psychiatric patients don't become involved with the law, even when they are ill. But Harcourt is a law professor not a clinician.

It is important to study the causes of incarceration and institutionalization; nothing in this commentary is intended to dismiss the topic or make light of it. My concern is that the use of conclusory statements, in the absence of data, leaves the article as nothing more than a political statement. We need more than that.

Monday, January 15, 2007

Sports Anxiety Disorder, Recurrent, With Psychotic Features

Blog-o-Mania alert: Shrink Rap gone wild, please see ClinkShrink's posts (with more to come) below.
My husband is getting off easy. Last time his team lost after so much promise, he ended up as the subject of an Op Ed piece in the Boston Globe. Now I have a blog.

He was thrilled when the Ravens made the play offs. Thrilled? Well, pleased, that's about the level of his halted expressiveness on things so important. Saturday morning, decked out in his Ravens sweatshirt, he was anxious. Very anxious. When they win it's mostly a relief. My son, who appears to be more mentally stable about sporting events while still being an avid and exuberant fan, was actually happy.

They lost.

Son was sad. He told me heard on the radio on the way home that three fans had committed suicide: I'm gullible enough to have believed him. Husband was morose. Sunday morning, he woke up and put his Ravens sweatshirt on. "I'm going to hope it was a bad dream and go down to the stadium at 4:30 and see what happens." This, I'm told, was a joke.

He TiVo'd the game. Now he watches bits and pieces, a way of processing his grief, I suppose, though it seems maladaptive to me. Move on. It's only a game. Now that's a sentence that would result in violence if ever said out loud where I live.

It's not in the DSM. It should be, perhaps with specific team modifiers.

Cyclothymia, seasonally influenced, Red Sox Nation fan.
---Please note, my guys are Red Sox and Ravens fans, with equal devotion.
Ravens Mania, not otherwise specified.
Borderline Eagles Disorder (for Roy and Carrie).


I'll leave it to Roy to blog about treatment options. Now there's a podcast for you.

My Patient Life

I met a very nice young man today. He wore a suit and a tie and a white coat and his hair was neatly trimmed. He took the time to explain to me what a white blood cell count was and how it could show how severe an infection is. He explained what the x-ray showed and why it was important to repeat the x-ray after treatment to make sure the problem wasn't something more serious. He did a very nice job with his patient.

When he came back with my prescription for antibiotics he said, "So, I just noticed that you're a doctor?"

"A forensic psychiatrist," I said, meaning "yes".

I don't use my initials when I'm off-duty. He may have been a bit embarrassed talking like he did to a physician, but I loved it. He did a wonderful job. Given the choice between being a doctor and being a patient I would always prefer to be the doctor, but in situations where I'm the patient I want to be the patient.

A social worker friend suggested that doctors who become patients get better care than "regular" patients, but this guy didn't know until the end of the appointment that I was a physician. I can't say whether I as a physician would treat a physician patient differently because so far I haven't had any doctor-prisoners. Maybe that's something Dinah or Roy could comment on.

Regardless, I'm getting the pneumonia treated. After the past three days lying flat on my back I will have another two days confined to the house avoiding contagion. It would be poor form to be the one to trigger an epidemic in a correctional facility. I will be relying on our readers and my fellow bloggers to keep me from going bonkers with boredom. So far I've only left the house for healthcare and groceries, and I'm going mad, mad, I tell you!

Library Card Meme

We were tagged by OmniBrain for this library card meme, but don't worry Dinah and Roy I've got us covered. Here is the library card for our Shrink Rap book, if we had one. (Uh, for those of you younger than X14 in hex code, library books used to be located using a card catalogue---4x6 inch cards with call letters typed on them. Sheesh, I feel old.) Dinah reminds me I forgot to add this: FEED DUCKS???

Sunday, January 14, 2007

My Three Shrinks Podcast 6: Advice on Manipulating Your Psychiatrist


[5] . . . [6] . . . [7] . . . [All]

Despite the Ravens' unfortunate defeat yesterday, we will still be able to provide you this new podcast (which was recorded last week).


January 14, 2007:
Topics include:
  • Emergency calls: what constitutes an emergency, and how do psychiatrists handle after-hours calls?
  • Phone messages: what do shrink-types put on their voice mail greeting, instructing patients what to do in an emergency?
  • Top 10 Favorite Search Phrases for 2006: includes such classics as "how to worry your psychiatrist", "advice on manipulating your psychiatrist", "sex with fish", "how to talk to your shrink so he will listen", and "how to get cats from under the floorboards".
  • OmniBrain kudos.
  • Beta Blogger Blues.


Find show notes with links at:
http://psychiatrist-blog.blogspot.com/2007/01/my-three-shrinks-podcast-6-advice-on.html

This podcast is available on iTunes. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.



Saturday, January 13, 2007

It Didn't Go So Well

GO RAVENS!!!


Everything here is purple.

Including our esteemed state legislators.


Go Ravens, beat those Colts!
--my sentiments with love to my guys who will be there screaming their lungs out!


Thursday, January 11, 2007

My Big Fat Hissy-Fit


[Note: I sat on this post for a day to cool down and think about it. The title has been changed three times and I also removed a few triple exclamation marks. I've downgraded my rant from a Category IV to a Category II.]

I am about to have a screaming banchee hissy-fit. Consider yourself warned. I've been blogging for almost nine months now and so far have never gone on a full-fledged, died-in-the-wool rant. I am about to make up for lost time.

The topic is an article on CNN that was just posted an hour ago. It's a story about a New England Journal of Medicine paper regarding mortality rates of prisoners who have just been released. I haven't seen the full article yet, but as reported it involved "26,270 men and 3,967 women released from Washington state prisons from mid-1999 through 2003". It doesn't say how the causes of death were confirmed, but the study found that newly released offenders were 3.5 times more likely to die within two weeks of release than an age, race and sex-based comparison group. The most common cause of death was overdose followed by cardiac disease, homicide and suicide.

To all of this I say: "No kidding! How much money did you spend figuring this out?" We knew twenty years ago that incarceration had some protective effect. In 1987 the Johns Hopkins School of Public Health looked at mortality rates among Maryland prisoners and found that age-matched prisoners actually lived longer than men out in free society. The CNN article also noted that the increase in post-release death rates were replicated in studies done in Europe and Australia.

What am I ranting about? It's this except here:

Other experts said the results don't surprise them, because inmates have far more physical and mental health problems than other citizens, (and) often get inadequate treatment behind bars...
There ya go. It's obvious, isn't it? If they're locked up then by definition they are getting inadequate care. It's axiomatic. It's also a knee-jerk stereotype.

Excuse me? Didn't you just say that they die after they get out? Who do you think has been keeping them alive all those months? Are you about to suggest that every patient who dies after discharge from a hospital was obviously neglected while they were inpatient? What planet are you on?

The thing they aren't mentioning is that they have no way of knowing how long the offenders would have lived had they not been incarcerated. These people live dangerous, high risk lifestyles. They annoy other criminals and get murdered. They kill themselves. While they are incarcerated we generally manage to keep all of that from happening. I don't like reading about my patients in the newspaper when they turn up dead after release, but it happens. I really don't like it when people suggest it's because I didn't do a good enough job while they were inside.

The only useful thing about this article that I liked was the conclusion:

Rather than saddling emergency rooms (and taxpayers) with the cost of providing post-release health care, we need to find a model of continuing care for ex-offenders.

Amen. And when we get that accomplished we will have a model for the rest of free society. Ya gotta start somewhere.

Thanks. I feel better.
*********

Addendum: The print version of this story that came out later that day did not include that aggravating phrase. Instead, it concluded this:
Cause (of death) often is overdose of narcotics after forced clean years, study finds
In other words, they lose their tolerance for drugs when they're locked up and so they are more likely to die of accidental overdose when they relapse after release.

Shrinky Stuff

I was at a shrink meeting the other night, and was handed the usual pile of papers. One of them included a letter from a psychiatrist named Michael Blumenfield at New York Medical College. I happened to notice that his signature included, "podcast: www.shrinkpod.com" --seems we're not the only podcasting shrinks, and Dr. Blumenfield does more of an Interview with the Experts thing, definitely worth checking out: Shrink Pod .

And another link: Journal Watch, Medicine that Matters, the depression/anxiety page at: http://www.jwatch.org/cgi/collection/depression-anxiety

Any psychopharm updates, Roy???

Is Ignorance Bliss?


As I've mentioned, I have coffee every morning with a judge in hair curlers while our dogs romp.

The judge walked in and announced, "I saw So&So at the mall last night holding hands with a woman."

Funny, but So&So had the very same, very unique name as my husband.

"Huh?" I replied.

"I saw So&So at the mall last night holding hands with a woman." Pause. "Only when I got closer, I realized it wasn't So&So, but it was a guy who looked just like him." Oh good, breaking up my marriage wasn't on my ToDo List for today, and I just wouldn't have had time. If my husband is in love with anyone other than me and the entire Ravens football team (none of whom would pass in drag), I missed it. I guess he has a look-a-like out there with a girl friend.
"Anyway," the judge continued, "I realized I didn't know if you wanted me to tell you if I found out your husband was having an affair."

"He's not going to have an affair," I said. He told me years ago that he was going to get a nice car instead of having an affair, for his midlife crisis .

"It's always a surprise," she said. "You can put it on the blog." There are now several people in my life who tell me I Should Put It On The Blog.

"What's this got to do with psychiatry?" It is a psychiatry blog, afterall, though ClinkShrink would have you compare treating patients to dishing up Bic Macs. How does she see that many patients? And can it really be psychiatry? I think she must walk through the bunkers (or whatever they're called) shaking haldol sprinkles out on everyone.

"Sure, it's a psychologically loaded issue."


I didn't know, maybe ignorance is bliss. CoffeeFriend2 (and dog, Prize) walked in and she was clear, she wants to know if her husband is found cheating.

So&So came home from a long day at the office.

"Judge wants to know if you want her to tell you if she finds out I'm cheating on you," I said.

"Yes," he said.

Okay, everyone, no affairs, the spies are out there.

Wednesday, January 10, 2007

Over 20 Billion Served


I got my 2006 statistics today. Coincidentally, my facility also had its annual surprise state audit today so the numbers came in handy. I have seen 10% more patients this year than last year at just one of my many work sites. I see as many patients in a given year as some small regional hospitals admit. Just out of curiosity I sat down and ran some numbers using very very conservative estimates, and I figured that over the time since I've finished my training I have treated at least 35,100 inmates.

I wasn't planning to blog about this, except that over at JR's Thumbprints recently he was posting about his recent audit and his prison system's factory approach to education. He was exactly right---how do you know what numbers are 'right'? If I see 3000 patients a year am I a better correctional clinician than someone who 'only' sees 1000 patients a year? What if there are actually 6000 inmates who need to be seen? Or only 500? Are we missing our target or overshooting?

The emphasis shouldn't be solely on the size of your clinic (although to be fair many correctional systems probably can't even give you an estimate about that) but it should also include measures of how long it takes someone to get seen once they're identified as needing treatment, how well they are tracked through the correctional system and how well the system is able to identify returning patients. There's just more to good quality control statistics than caseload size.

To quote that old Wendy's commercial: "Where's the beef?" My beef is here---with the numbers.

Tuesday, January 09, 2007

My Three Shrinks 5: Sex, Lies, and Neuroeconomics


[4] . . . [5] . . . [6] . . . [All]


Today's podcast is brought to you by the letter "M" and the number "5".



January 9, 2007:
Topics include:





Find show notes with links at:
iTunes. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

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Monday, January 08, 2007

Lifestyles of the Shrink Rappers

[posted by dinah]
It suddenly got very quiet here at Shrink Rap. I think ClinkShrink's geek roar has drowned everyone out. I'm wondering if she even noticed that I'd claimed her post as my own. As I've said, "Dream on."

So this is dedicated to Jessica, a 3rd year medical student, who commented on one of my recent posts. Jessica writes:

Hi, I am a 3rd year medical student that will probably go into psychiatry. I
enjoy your blog a great deal.This post contained a lot of new info for me - when
I tell people my intended field, they say, "Well, at least the lifestyle is
good." I had no idea that you were expected to be available by phone within 30
minutes 24 hours/day. I had always heard that psychs told their patients to go
to the ER if there was an emergency. Or if they were faculty at a learning
institution, to "page the on call psych resident." Also, can you comment on
psychs not having secretaries, and group v. solo practices? Thanks, Jessica


Thank you, Jessica, we Rappers (or Shrinksters) always like hearing that our blog is enjoyed. I've been thinking about your questions since I saw them and this is what I come back to.

When it comes to choosing a medical specialty, go with your heart. There is no other way. Psychiatry is so different from everything else that it needs to call you, even if just a little. If nothing or everything calls you, think long and hard about it, visit docs in their offices, talk to everyone you can, and hey, visit a blog or two!

In my eighth grade English class, we were assigned to do a research "career report." One classmate ventured into New York City and met with Chuck Scarborogh-- he wanted to be an anchorman.
Newton (Now NJ), I am pleased to report, is now a newsman with Eyewitness News, and apparently I'm not the only member of Mrs. Garelick's class to have a podcast.
I wrote about how I was going to be a psychiatrist. What was I thinking? At that point in my junior high school life, I'd never met a psychiatrist and I'd never even met anyone with a mental illness. The best I can figure is that I liked teeny bopper magazines and thought it would be cool to be one of the "experts" who got quoted about human behavior. I found a book on Freud's theories in the library and thought this was really weird stuff. I did not, I repeat, did not, have penis envy.

In med school, I had several profs express concern that I was wasting my life. One suggested I would be more useful to society as a cosmetic surgeon. During internship, a cardiology fellow told me he'd wanted to be a psychiatrist but instead he had his own psychotherapy and realized that was what he was looking for. That actually is a good point: if you're looking for answers to your own problems, get a shrink, don't be one, at least not for that reason alone. Many people told me that in psychiatry no one ever gets cured. They were wrong.

But what if you wrote your career report on becoming a ballerina, and now you're in the throes of a medical education, having survived organic chemistry and MCAT's, trudged through biochem, anatomy lab, and 4:45 AM cardiothoracic rounds (do they still do that?) and nothing is screaming your name? I'm not sure what to say, I haven't been there. Process of elimination, maybe. If it's lifestyle you're looking for, I think dermatology is low on crises. There are many ways in many specialties to gain some control over your time: if lifestyle is important, stay away from trauma surgery, OB, and most other surgical subspecialties.
For what it's worth, though, I agree, psychiatry can include a good lifestyle, though easy hours won't bring in the big bucks, but you can have time to spend with your kids and your blog.

Seriously, though, I was unaware of the AMA dictate that psychiatrists be available for emergencies within 30 minutes. Every shrink I've mentioned this to has gotten a bit anxious and no one has heard of this (except Wise CoveringDoc). Even Camel who carries a "Life or Death" line with her was not pleased. This little-known statement applies only to emergencies (not availability on demand for anything your heart desires), doesn't define emergencies (I don't think, hmmm, I've never actually read it having learned of it 3 days ago) and emergencies in private practice are not that common, at least not in my practice. The one time I was called with what was truly an emergency-- a patient on the brink of a suicide attempt-- I answered the phone, thereby being immediately available, not even a one minute wait, and the caller went through with the attempt despite my wise counsel (I did call 911, the caller did survive). I'm not losing sleep over this one, though it did occur to me yesterday that I'd left my phone in the car while I was at the gym for a one-hour work out and if someone had an emergency at the beginning of my workout.... oy...I stayed on the stairmaster.

Solo versus Group: I've done both. I was in a group for 7 years, I liked it, I left when the logistical issues of office space got to be difficult. The group had 3 billing secretaries, I've done better on my own. I've never wanted secretaries to schedule me, though they do in the clinics where I've worked, and usually it's fine.

I'm actually a pretty good secretary, if I do say so myself.

I hope this helps.

Sunday, January 07, 2007

I Am Geek Hear Me Roar

[posted by Dinah. Dream on. What language is this anyway?????]
I know this post is going to carry a bit of schadenfruede, but trust me that I am not trying to gloat over Dinah's late lamented cellphone. I am posting to celebrate a small victory.

I am writing from my new Linux laptop using the Iceweasel browser. Actually, it's my old Windows XP laptop that I've booted from the CD drive using a Knoppix live CD. I got interested in Linux after exploring the command-line Unix terminal in Mac OS X. That got me curious, and after reading around a bit I learned you could get ahold of CDs that you could use to boot your machine in other operating systems. (Remember the old days when you had to put a floppy disk in your machine to load the operating system? Back before hard drives were invented?) Anyway, first I tried DSL (Damn Small Linux) which was pretty amazing. It was a fully functional Linux operating system capable of recognizing all my peripheral devices as well as running all the usual desktop applications---it even had development tools and a small Web server installed---but it was small enough to fit on a thumb drive. A 50 megabyte operating system---incredible. It was a taste of Linux, but it wasn't enough. Then I found Knoppix and over the weekend I downloaded the latest release---version 5.1 released one week ago. (Even on a high speed connection a 700 megabyte download is painful.) I burned it onto a CD and hit the F12 key to boot from the CD/DVD drive. Beauty! It was a thing of beauty! It automatically recognized my entire laptop---trackpad, monitor, video card, hard drive and two USB external drives. It came with a full OpenOffice package (which I heartily recommend for people instead of shelling out money for the latest Office version---which now comes stripped of Outlook). It also has two browsers, a web server, a design environment (software you can use to write software), loads of cool system tools and tons of other stuff I haven't had a chance to explore yet. (Roy would really like the fact that when your desktop gets too cluttered you can just tell Linux to create a new desktop, and you can switch between them.)

And the thing that kills me about this is that it's all free. Anybody could do this. You just download it from the Internet. The wireless card took a little tweaking to get configured, but I managed to get connected this morning (thus, this post).

So why do I put this on ShrinkRap?

I'm doing this for the geeks. For everybody out there---you know who you are---who has ever felt the irrepressible urge to tinker, tweak or chew on a problem until it's solved. You are probably a former ham radio operator. You have probably opened an appliance or two just to see what's inside. Your friends, spouse and colleagues probably don't have a clue what you're talking about half the time but that doesn't stop you.

I want you to know: it's OK, you're among friends here.

Friday, January 05, 2007

And How Was Your Day?


[posted by dinah]

Before I start:

ClinkShrink, please forgive me for posting over you. I need to vent, badly. I'll never do it again, really.
World: Please scroll down to Clink's wonderful post on
Keeping The Faith, it's really great.

We've been talking about coverage, returning calls, standards of care: see the posts below (below Clink's wonderful Keeping the Faith post).

So, this stuff has been on my mind, and I've been thinking about Older & Wiser CoveringDoc's Guest Blogger comments about the expectation that emergency calls should be returned within 30 minutes.


So, this morning, I'm steaming my wrinkled clothes and I hear my cell/office phone. Normally, I'd let it roll to voicemail, but I've got this blog stuff on my mind, so I go glance at the number. It's a familiar number and I think it's a patient who recently had a suicidal crisis over a holiday (and yes, I called back on the weekend, several times). I answer the call, only it's not that patient, it's someone new, looking for an appointment, she tells me her name (which never registers) and who referred her. The steamer is on in the next room, my schedule is downstairs, I ask if I can call back in ten minutes. I don't have a pen/paper, but that's okay, the number is on my cell phone, I'll call right back. Ten minutes. I finish steaming, get dressed, grab my cell phone, coffee cup, and a basket of laundry and head downstairs. I throw the laundry in the wash, find my schedule, and go to return the call. Where's my cell phone? And, I think, as I call it from the house phone and don't hear it ring anywhere, what was that funny clunk I heard when I started the laundry? Well, I find my cell phone, very clean and very dead, in the bottom of the washing machine. It's now 9:30 and I have my first patient at 10, I need to get going, but my office line is my cell phone, so I'll have no phone for the day. Sort of panicked, I change my voicemail message, noting that my phone has been submerged and that I may have trouble both retrieving and returning calls for the day (please don't report me to the shrink police, CoveringDoc). I leave a message for the psychiatrist across the hall letting him know I will be showing up in his office to borrow his phone and check my messages. And then I remember the new patient who wanted the appointment. I don't know her name, I don't have her number, I feel awful as I'll just be totally blowing her off, and my final call before I dash out the door to my phone-free day is to the referring psychiatrist. I leave a message on his machine (but I don't dial his emergency number) asking if he could leave me a message if he knows who he referred to me and has a phone number.

It should have been a quiet day, but I was a little anxious without my phone (think Linus and that blanket). My husband called, heard the message and suggested I get something waterproof-- this is my second drowned phone.

So, I'm spending friday night learning to work my new phone. Referring doc actually had phone numbers, and 9 hours after my promise of "I'll call you back in ten minutes," I reached the prospective patient, apologized profusely and explained the drowned phone in the laundry story, and somehow she still wanted an appointment with Ditzy Doc (that would be me).

And what did you do today?