Monday, April 30, 2007

Quacking it up for Grand Rounds at Shrink Rap


We're getting ready for Grand Rounds here at Shrink Rap. We've read, we've written, we've eaten chocolate, we've podcasted. Roy is in his element. No BYOB here, I provided the beer, Roy and Clink the brains.

To be sure, our first subject heading will be something ducky, perhaps The Central Duckus.


For those who've joined us late, I'm Re-Publishing the original post about Emotional Support Animals inspired by a May, 2006 New York Times article, written a bit less tongue-in-cheek than one might imagine. I can't seem to get the pic of the Emotional Support Dog over, but you know I tried. Our lives have not been the same since, now get that Duck into the oven:


Beth Landman writes in Wagging the Dog, and a Finger:


The increasing appearance of pets whose owners say they are needed for emotional
support in restaurants — as well as on airplanes, in offices and even in health
spas — goes back, according to those who train such animals, to a 2003 ruling by
the Department of Transportation. It clarified policies regarding disabled
passengers on airplanes, stating for the first time that animals used to aid
people with emotional ailments like depression or anxiety should be given the
same access and privileges as animals helping people with physical disabilities
like blindness or deafness. These days people rely on a veritable Noah's Ark of
support animals. Tami McLallen, a spokeswoman for American Airlines, said that
although dogs are the most common service animals taken onto planes, the airline
has had to accommodate monkeys, miniature horses, cats and even an emotional
support duck. "Its owner dressed it up in clothes," she recalled. There have also
been at least two instances (on American and Delta) in which airlines have been
presented with emotional support goats.

Can I ask which designer the duck wore?

Saturday, April 28, 2007

Pay In Advance To Retreat: Part 2


OK, in all fairness I need to post about this. After all, we had a small catfight in Shrink Rap land over the issue of Sheppard Pratt's Retreat program. Now it's my turn to eat my words. Let others rage as they may, I promise to shut up and take it.

This just in from the New York Times: Booking a Cell in a 5-Star Jail.

Apparently Orange County has a number of facilities where selected inmates can pay anywhere from $82 to $125 dollars a day, in advance, to be housed in a nice clean safe single-cell facility where they are allowed to have cell phones and/or computers and where people can bring them hot meals. Dinah, have I got a jail for you.

Inmates are allowed to leave during the day to work but are required to have small jobs within the jail to keep the place clean. Proceeds from the "pay-in-advance" upgrade program go to underwrite the costs of other county facilities.

So what do I think?

I think it's a win-win for both sides. It spares the custody staff from having to protect high-profile defendants from the general population of gang members and it provides indirect benefit to the general population. Is it discriminatory? Sure. But if they were in gen pop they'd also be discriminated against---by the inmates themselves.

**********

Or for the truy adventurous, you can stay in the Ottawa jail hostel. For those who believe a jail should be a hostel environment.

Online Presidential Chat Room

Okay, I can't stop ROFLMAO after reading this nugget. (Warning: contains juvenile humor and offensive language.) Just had to let you know. This will be a classic.

Snippet:

** Hi11ary has joined chatroom **
** McCain has joined chatroom **
** BaRock! has joined chatroom **
** Da Mayor has joined chatroom **
** MiTT has joined chatroom **
** 4Honey has joined chatroom **

Hi11ary : Waz up Homies?
Da Mayor : Heh
4Honey : What up girlfriend?
MiTT : WTF? Who is 4Honey?
McCain : 4Honey, ASL???
4Honey : 53, Male, North Carolina
Hi11ary : Is that Edwards?!??
4Honey : :-)))))))
...
4Honey : u little biotchs! i m gunna kick ur asses
McCain : With what? ur giant hair?
Hi11ary : LOL!
4Honey : FU
** 4Honey has left chatroom **
BaRock! : LOL!!
MiTT : ROFL!!!!!!1!!
...
MiTT : doods, I raised some major bling
BaRock! : noob, I beat ya
Hi11ary : I p4wned both you
McCain : I sux
Da Mayor : Yup
BaRock! : LOL

Friday, April 27, 2007

Lost In Prison Space


We have a new metal detector. It's a doorframe type and it's very high-tech. It has a digital camera perched on top to take a picture of every person who walks through. It's attached to a laptop so it can display the picture immediately. If you're carrying something you shouldn't have a tiny little pointing hand icon pops up on the computer monitor to point to the place that the officer is supposed to search (apparently they think correctional officer training doesn't qualify one to figure that out). But the best thing about this new metal detector is that it talks.

Truly, I'm not kidding. When it's unhappy it blurts out "Warning! Warning!" in a voice identical to---I mean exactly like---the robot from Lost In Space. Every employee over a certain age breaks out laughing when they hear that voice. I think someone from the television industry gets paid a royalty every time it goes off.

The other interesting thing about the metal detector is that it's triggered by underwire bras. Yes, you are imagining this correctly---the little digitized finger is pointing out...um...non-contraband on occasional female employees. Ya just gotta love this place.

So now in addition to the doorframe detector all employees are also required to get a pat-down frisk. (Don't worry, the females are patted by female officers.) Just another unintended consequence of technology. I'm hoping soon they invent that electric bra.

*********

By the way, for only $24,000 you can buy an exact replica of the Lost In Space robot here.

Shrink Rap to Host Grand Rounds on May 1



Dear Readers,


First, don't miss our anniversary Podcast, #17-- scroll down for the show notes (and that great photo of our feet).

Send your submissions to mythreeshrinksATgmailDOTcom.
We plan to do a My Three Shrinks podcast about the submitted posts, as well. If you'd like to also submit up-to a 30-second audio to us, please do, and we may just include it in the podcast. (Just make an .mp3 and send it as an attachment... I'll leave it to you to figure out how.)


It is only fitting that we will be first hosting Grand Rounds (5/1) right after the first anniversary of starting Shrink Rap. In case you want to check out last week's (4/18) Grand Rounds, go to Fat Doctor. For this week's (4/25) Grand Rounds, go to Med Valley High.

What is Grand Rounds? To the uninitiated, the term "Grand Rounds" was traditionally a bedside teaching session for physicians. Instead of the regular, daily rounds which were conducted by individual physicians caring for their patients, at Grand Rounds a physician would bring a patient to a lecture hall, surrounded by scores of their peers and students, to be educated about a particular disease, evaluation method, or procedure. More recently, it has been a lecture
sans patient about a particular medical topic.

Nick Genes, of Blorborygmi, started an online version of Grand Rounds back in September, 2004 (here's the schedule of past and current GR). It's
mission is to "introduce a wider audience to the expanding array of talented doctors, nurses, techs and students writing online today.
" Various health care-related blogs have taken weekly turns collecting submissions for Grand Rounds, collating them into a cohesive group, then introducing them to the wider internet audience for all to read, learn, and be amused.

Grand Rounds at Shrink Rap:

BYOB (Bring Your Own Brain)



It is our turn this week, so here are the submission guidelines.

  • Deadline is Saturday night (April 28, 2007) at midnight PST (that's 3AM Sunday for us Easterners). We reserve the right to include stragglers, but no promises, okay?

  • We intend to include all appropriate submissions. We just don't have the heart selecting the top 30; and, besides, can you imagine the three of agreeing on which ones to include?

  • We will show a strong preference for highlighting posts with any kind of relevance to psychiatry/mental health/neuroscience/brain/behavior topics.

  • Please keep this in mind as you write posts this week or submit recent posts (the more current, the better). (If you really want to score brownie points, also relate it to quacking fowl.)


  • Send your submissions to mythreeshrinksATgmailDOTcom.

We will have our Grand Rounds up on Tuesday, May 1. See you then.
-Dinah, ClinkShrink, and Roy


P.S.: We plan to do a My Three Shrinks podcast about the submitted posts, as well. If you'd like to also submit up-to a 30-second audio to us, please do, and we may just include it in the podcast. (Just make an .mp3 and send it as an attachment... I'll leave it to you to figure out how.) Warning: this is Roy's idea... Dinah and Clink are trying to talk him out of it.



Brains...Must ...Have...Brains

Thursday, April 26, 2007

Shrink Rap Blog Hijacked by Grand Rounds Manic Roy

Roy keeps moving the Grand Rounds notice to the top of the blog. We're posting new posts, honest, just scroll down and somehow you'll find the new ones....
Oy.

[From Clink] I have a new post today (Friday), just keep scrolling down. Sorry about this. Things will get back to normal (HA!!!) after Grand Rounds.

Wednesday, April 25, 2007

Face to Face

Reminder: Grand Rounds at Shrink Rap, BYOB, Submissions due by Saturday.


Sometimes, The Last Psychiatrist says things that make me want to scream. He did that the other day, in a post about the Virginia Tech shooter, he made the statement, and I quote:

"... Cho wasn't mentally ill. He was a sad, bad man who killed people because his life wasn't validated. There was no psychosis, there was no cognitive impairment, there was no psychiatric impairment in insight in judgment. There was a lack of sex, but that's not yet in the DSM. Not to reduce his life down to a soundbite, but he was a guy who thought he deserved better by virtue of his intelligence and suffering; found himself in a sea of mediocrity but couldn't understand why he couldn't therefore excel; and, worst of all, found that all the things he thought he deserved eluded him-- especially hot chicks, who not only dismissed him and found him creepy, but, worse, chose to be with the very men he thought were obviously inferior to him. "

Can I scream??? I don't want to defend this man, I haven't followed the news all that closely, and I watched one 3-minute video the killer made, though I will admit that statements he made along with some of his behaviors (for example, killing himself, or perhaps even the illogical thought process that might lead one to think that murdering innocent people makes one a martyr for one's nonexistant children) led me to think he might have a mental illness. On our podcast we talked about this in response to a reader's question and we didn't think a diagnosis of schizoid personality disorder was necessarily accurate or not, and we didn't think it was relevant to the act of mass murder.

I don't know how The Last Psychiatrist practices psychiatry. For me, when I do an evaluation of a new patient in my ideal bubble world private practice, I schedule 2 hours, I sometimes run a little over. I ask the patient about every aspect of their lives, including extended family history, descriptions of their parents' and siblings' personalities, detailed medical, occupational, romantic, legal, military, and habit histories. I ask about past episodes and treatment. I do a mental status exam. I request records, if someone accompanies the patient, I bring them in at the end of the interview to clarify history, get another perspective, talk about a plan. In less-than-ideal clinic world, I take a history and I often have extensive records from prior treatments.

I've never made a diagnosis based on a three-minute tape, one where I didn't get to ask questions.

How does The Last Psychiatrist know there was no impairment in insight or judgement (Give me a break, he thinks this guy had intact insight and judgement?) How does he know Cho didn't have sex? How does he know Cho was motivated by his anger about not getting the hot chicks?
Did I miss something here? The Last Psychiatrist seems to know an awful lot about the inner thought processes of a stranger.

Thanks for letting me scream. I'm done now.

Tuesday, April 24, 2007

If I saw this bumper sticker on a car, I think I'd crash

Shrink Rap to Host Grand Rounds on May 1st
BYOB: Bring Your Own Brain
Submission Deadline Saturday at Midnight



And scroll down to Disturbing News to read about Clink's rough day.


My thought for the day (stumbled on with regards to Lily of DrivingMissMolly):


Disturbing News


I wasn't originally planning to blog about this, but today's news about the riot at the Indiana prison brought me to it.

Our facility was overcrowded recently due to the closing of another prison. We were running 200 inmates over capacity. A conference room on the administrative floor was temporarily turned into a housing area, with mattresses on the floor at night and all through the weekend. During the day when the conference room was in use the inmates were transferred to a single holding cell across from my department.

On the day in question it was hot. Not Life In Hell hot, but uncomfortable. It always takes a couple days for the institutional ventilation system to catch up to the external weather. The inmates were crowded together with no showers, no recreation and no commissary.

When an officer opened the door to let someone out, an inmate charged the door. Voices were raised and got loud. Then louder. Then louder. I heard the officer radio for assistance.

The holding cell was across from my department. I was alone with our secretaries. When the noise level rose I went out to check on the action, thinking it might be wise to have a shrink available to intervene.

What an idiot.

Stupid, stupid, stupid.

Note to self: do not run into a burning building when you are not carrying a hose.

Do not walk toward a pending riot when you are not armed.

Fortunately the black shirts arrived first---a swarm of front line officers, a duty lieutenant and a major. I retreated back to the department and planned an escape route and made sure the clerks knew what to do. (I sure hope the locks on the back office work like I hope they work.)

The loudest inmate calmed down and custody made arrangements to take them out for showers in groups of five. The holding cell was locked back up and no one was injured. The next day 60 inmates were transferred out and now we're back to normal. Life is good.

What happened was understandable given the conditions, but consider Indiana: The prison was only five years old so presumably the ventilation, temperature regulation and cleanliness were all reasonably good. The facility was significantly under census, not crowded. The inmates transferred there were specifically chosen to be non-violent offenders.

It can happen at any time, at any place, for any reason. Here's keeping my fingers crossed for my colleagues in Indiana.

Monday, April 23, 2007

My Three Shrinks Podcast 17: Happy Anniversary!


[16] . . . [17] . . . [18] . . . [All]

This podcast comes out the day after the 1-year anniversary of our blog. Thank you to all of our well-wishers. It's not always easy to keep something like this, and the podcast, going. But having friends like Dinah and Clink make it easy.

Note that next week will be a special podcast, where we will discuss many of the submissions for our May 1 Grand Rounds. Send us your submissions by Saturday, April 28, 2007, at midnight at mythreeshrinksATgmailDOTcom. We'll even include some brief audio comments about your post (attach a 20-30 sec .m3).

April 22, 2007
Topics include:
  • A lot of silly talk about our anniversary, gifts, ducks, and chocolate.
  • Virginia Tech Tragedy. Most of the podcast is about this and related offshoots. We discuss some comments on Dinah's post, Unspeakable. We also point out two past posts, Suicidal Students and Let's Talk About Suicide.
  • This CBS News story discusses the struggle of balancing privacy and safety on college campuses.
  • Dr. Michael Welner, a forensic psychiatrist consulting for ABC News, criticized the media for showing the videotapes from Cho Seung-Hui (more here). (What is "Ismail Ax"?)
  • NAMI has some useful links related to this tragedy.
  • Clink lists other bad events which have happened in the third week of Aprils past, including things to do with Hitler, Lincoln, Oklahoma City, Waco, and Columbine.
  • There are two Mental Health Parity bills before congress. Please let your U.S. Representatives and Senators know you want these passed unamended.
  • Psychiatric News reports that the number of medical students choosing careers in Psychiatry is holding steady at 1000 entering psychiatry residencies this summer.




Find show notes with links at: http://mythreeshrinks.com.
This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening.

Saturday, April 21, 2007

One Year of Shrink Rap!


Happy Blogiversary to Us!

Here's to One Year of

Shrink Rap


With many thanks to ClinkShrink and Roy for indulging my whim.
Scroll Down to See WHY we blog, compliments of Fat Doctor

Why Do We Blog?

[From ClinkShrink]

Fat Doctor has tagged us with a Why Do I Blog meme. I happen to be up sipping coffee this morning and this is a fairly decent way to avoid going off to work, so I'll go first.

1. Because Dinah asked me to.
I think over the twenty years I've known her I can't recall ever turning down an invitation from Dinah to do anything. I've always had fun doing things with her. As far as invitations go this might be the most out-of-the-ordinary thing she's invited me to do---usually it involves cookouts or dinners or other get-togethers as opposed to the things that I invite her to do like going rock-climbing or attending lectures on human sacrifice. She's hard to resist.

2. I get a fellow geek to play with
Roy is one of the few people I've ever met who "gets" the stuff I talk about with regard to computers. He's taught me a few things, too. If something gets tweaked or touched up on our template I know where it came from and I never question it. Even better, he comments his code! God bless coders who comment (you programmer types know what I mean). And he makes good puns.

3. Blogging forces me to think about things
This has unexpectedly turned out to be a great means of continuing medical education. When I read journals now I subconsciously scan them for things that would be interesting to blog about. I'm reading medical literature with a different level of attention than I was before. And I get to learn from my co-bloggers---bless Roy for the FDA updates, and Dinah for summarizing the antidepressant study.

4. People in "free society" need information
When I go to work every day it just hits me how little most people know about the correctional world or the problems faced by healthcare practitioners there. I have a running internal debate about how much information is "too much information" but I parse it out as tactfully as I can. I may or may not blog about a near-miss incident in my institution yesterday.

5. I get to hear what other people think
I read other peoples' blogs and I like reading comments on our blog. Patient blogs should be mandatory reading for physicians-in-training. They are vivid in their descriptions of living "inside" the disease. I like the fact that we're getting more non-North American commenters and I hope that continues.



[From Dinah]

1. Writing: I love to write and this is an avenue where I actually get willing readers and responses. Wow! And Thanks.

2. Expression: Shrinking inspires all sorts of thoughts and emotions and here I get to express my ideas and feelings here in a way that forces me to be more articulate about them than I would otherwise be, and sometimes lets me express emotions in a way that's a little more raw than my real life persona.

3. Pure narcissism.

4. Friendship: both real (as a real life endeavor with my dear friends Clink & Roy, now with My Three Shrinks podcast time) and virtual, with people interested in talking about psychiatry.

5. Expanding my horizons: I've now "met" someone whose child eats dog biscuits!
(Just teasing you, Fat Doctor!)

I want to tag: Shiny Happy Person, The Last Psychiatrist, Flea, Midwife With A Knife, and the Musings Of a Distractible Mind Doc.


[from Roy]
1. Because Dinah asked me. (No, I wouldn't jump from the Empire State building.)

2. Creative outlet (I have a pathologic need to inflict my bad puns on others.)

3. I love hearing others' perspectives on issues that are important to me, especially folks from other countries.

4. I've always liked to share information and explain things to others, particularly about Psychiatry, which is, unfortunately, a misunderstood field, particularly as it intersects the broader field of Medicine.

5. I really do it for the
ducks.

Friday, April 20, 2007

Unspeakable


The Shrink Rappers have been quiet for a few days. It's hard to know what to say. I've called Clink, told her she has to post, I'm sure she'll have some thoughts soon. My oldest is thinking about colleges, here stands a reminder that safety, both ours and our children's, is a just an illusion. For everyone, my heart wraps around the unthinkable grief and sadness-- mostly it's too painful to even watch for more than a few minutes.


The New York Times ran a piece today about mass murders and mental illness, it didn't say much of substance. Cho was angry, maybe he had a personality disorder-- they speculate on which one, avoidant, paranoid, perhaps he was depressed or psychotic. Certainly, he was angry, and the article starts by saying he had a hole in his soul. I don't know what that means, but it sounds like as good a way to explain the inexplicable as any.


Sometimes, people tell us things about their mental life that suggests a diagnosis, at least an explanation. The depressed person who commits suicide out of guilt, pain, and hopelessness. The person who kills someone because voices tell them the victim is going to kill them, as distorted as it is, we get that in this person's mind, it is self-defense.


I watched a few minutes of the video. Cho Seung-Hui was filled with rage, he felt victimized, in the little I've seen, he didn't say why. Somehow, he believed his actions made him a martyr and he deemed this an act done for his children (---?). Somehow, in his mind, it made sense. He'd been hospitalized once briefly a few years ago, perhaps he had a diagnosis, as somehow we'd all like something-- an explanation, someway of grabbing on to this and believing we might catch and prevent acts that linger between severe untreated mental illness and pure evil.


Whatever it means, Cho Seung-Hui most certainly had a hole in his soul.

Tuesday, April 17, 2007

I Don't Charge Enough

First, I feel like as bloggers, we're becoming oddly linked in blogging rhythm: we've all got Springtime blogging mania and the posts seem to come in bursts.

Scroll down for:


  • Podcast 15, by the lovely Clinkster

  • Fat Doctor Feeds Her Kid Dog Biscuits, by Yours Truely

  • Clink's thoughts on altruism in Because it Feels Good

  • Dinah's review of Reign on Me as You Order Salad Like a Shrink

  • Roy's thoughts on Shrinks on Call in : ER Call

  • and finally, both Roy and Clink did a synopsis of the Shrink Rappers' venture out in their dueling posts on Human Sacrifice in Moche Culture. Will I ever get these folks out for crabcakes and beer?

And that was all in the last 72 hours, we're a very busy blog!


Okay, Okay, This post is called I Don't Charge Enough and it was inspired by the fact that a patient told me today she was glad to see I'd raised my rates, I undervalue my services (yes, she was serious), and if that wasn't enough, I came home to a blog comment by Sophizo telling me I don't charge enough, and a shrink she knows gets $300/ hour.


I don't charge $300/hour.


Okay, so I left residency and in addition to a job I got, which I think paid $42/hour (this was a while ago), I joined a private group practice. My fee was set by the group, it was about $10/ hour over going rates, but there were secretaries who submitted directly to insurance, the patient only made the co-pay, and in a fit of total ignorance, I joined the Blue Cross network, not realizing that by doing so I was discounting my fee by roughly $35/session, often to people who could well afford to pay full-fee. I stayed with the group for years, during which time my fee didn't change. I left to go out on my own, solo, no secretary, and I opted out of Blue Cross, didn't take insurance, and my patients were left to pay full-fee and struggle by themselves with their insurance companies. My fee was now on the low side, but with this new burden on my patients, I couldn't raise my fees, I just couldn't. Time passed, I still couldn't raise my fees. More time passed, I was having an issue. My rent went up, everything else went up. Somewhere in there, I changed my other job and made more money at that. My husband's career was going well. We wanted for nothing. So 12 years later, and my fee was exactly what it was when I started my private practice, I was embarrased when other shrinks asked what I charged, more embarrased when I saw the look on their face and heard how much more they were charging. I had an issue.


On the one hand, the I-don't-take-your-insurance policy scares a lot of patients away. But, it doesn't mean that I see only rich people: I have patients who struggle, who enjoy few of the luxuries in life, who rarely go to an extravagent restaurant, never purchase new cars, never go on vacation. They pay out of pocket, and this is their choice: there are cheaper places to get treatment and I work at some of those cheaper places. For those who want psychotherapy with a psychiatrist, however, out-of-pocket is often the only way to get it. Some of my patients have no health insurance and foot the whole bill. They come as they can, I don't make demands that everyone come at a certain frequency, but for those who come weekly, or even bi-weekly, psychotherapy is expensive. Let's see, at Sophizo's suggested $300/session, let's say the average patient comes 45 times a year given their vacations, my vacations, holidays, sickness, snow, whatever--$13,500/yr, up front and hope your insurance sends you back $60/session if they're generous. Sorry, Sophizo, I might be richer, but this isn't reasonable to ask from anyone. Even at my undervalued fee, psychotherapy is a large, regular expense, it's hard for me to ask that of struggling people who are suffering. As is, my fee is hard for some patients, they are giving up something else to be my patient. I hope it's worth it.


On the other hand, there is this funny message that I undervalue my work, I don't want to think and I don't want anyone else to think, that I'm worth less than the guy down the hall (by definition, I am-- my patients tell me everyone else's fee, I believe I'm the cheapest on the hall) and while I've finally caught up to the standard fees, I still charge on the low end.


So after years of grappling with this, I'm left to say that it's fine that I charge on the low end--- I have lower overhead than a lot of docs who pay secretaries and have large offices, my fees are discounted only by Medicare and I don't have many medicare patients, I want for nothing and I wish that I could do this for free enough that I take an occasional pro bono case and recently started volunteering a couple hours a week for a great organization that serves the neediest of the needy. Is that altruism, per Clink? It makes me feel good, it's my way of giving back to a world that educated me with scholarships and low-interest student loans, to a world where I've spent more time helping the suffering than being the sufferer, and something about it makes my life richer-- not altruism. In all honesty, perhaps a funny mix of gratitude and guilt. That's okay to admit, right? And did I really just write a post trying to justify why I don't charge more?

My Three Shrinks Podcast 16: Encyclopedia of the Weird


[15] . . . [16] . . . [17] . . . [All]


ClinkShrink here. I volunteered to help Roy by editing one of our podcasts--heaven help me, I did the best I could. Be patient, I'm using Windows. This is podcast number 16 which was actually podcast number 14 taped about a month ago and taken out of order for no particular reason.

April 17, 2007
Topics include:


  • First up are the Top 25 Crimes of the Century, a topic that could only be mine. It's a Time article that lists some of the most infamous or unusual crimes, but I have a couple bones to pick about their choices. Roy and Dinah just think I'm weird for even knowing this stuff. [Listen in to find out Clink's favorite crime. -Roy]
  • Next we answer a question from Driving Miss Molly regarding how much and what kind of preparations psychiatrists do before their patients' appointments.
  • Finally we do the Shrink Rap blog rollcall, where Shiny Happy Person deals with medical training in the UK and under the NHS, Roy flirts with the Girl with the Blue Steth, and Intueri talks about bipolar disorder in kids.
Find show notes with links at: http://mythreeshrinks.com. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening.

Monday, April 16, 2007

SCROLL DOWN FOR POST ABOUT FAT DOCTOR!


From Clink: Once again, I end up having to find a picture for Dinah.

Because It Feels Good

See other Savage Chicken cartoons here

The Psychology Of Altruism

I saw a story in our local newspaper recently that summarized the results of a Johns Hopkins survey of people who volunteer for research projects. The projects they were looking at were Phase I clinical drug trials, in other words studies that are done using drugs on humans (as opposed to animal) subjects for the first time.

It led to the obvious question: Who the heck would do something like that?

Now, I knew a couple people who volunteered for studies when I was an intern. They were both rather adventurous, young, and somewhat in need of money. Looking back on it I could say that they were trusting people who believed that the researchers wouldn't do anything to seriously put them in harm's way and that they were also fully armed with the youthful denial of any possibility of death, disability or adverse consequences to many things they did.

Some of the subjects in the survey reported that they essentially became professional guinea pigs, even travelling from state to state to make a relatively lucrative living (lying to the investigator in the meantime about their extracurricular research activities). However, about half the volunteers were employed at the institutions where the research was being done. They reported that volunteering made them feel good that they were helping people.

That got me thinking about altruism in general. We have many examples of altruists in our society: parents, volunteer firefighters, soldiers, people who sign organ donor cards or send money to charitable organizations. What leads people to give up something when there is no immediate benefit to the giver? Or worse yet, when there are always people ready to take the benefit without ever making a sacrifice in return?

There are religious motivations for altruism, but this being a psychiatry blog I thought it would be more relevant to look at the psychology and evolutionary biology of altruistic behavior. (Don't worry, I'll keep it short to avoid being snooze-worthy.)

In The Ego And The Mechanisms Of Defense Anna Freud described the concept of "atruistic surrender". I'm admittedly nowhere near being an analyst, so if any reader out there has a better handle on this than I do feel free to enlighten me. As best as I can figure it out, altruistic surrender takes place when a patient's unconscious conflicts are triggered by superego suppression of impulses. To manage the resultant anxiety the patient projects the forbidden impulse onto someone else, identifies with that person, then works to help that person satisfy the impulse. For example: someone feels the urge to eat lots of gourmet food but this impulse triggers an unconscious conflict. The impulse is attributed externally: "I am not hungry. They are hungry," and the person throws herself into feeding the hungry or cooking extravagant meals for friends and family.

Whew. This must be why analytic training takes years.

The evolutionary perspective is much more simple-minded (lucky for me). A behavior survives for one of a few reasons: it's good for your relatives, it helps you have more kids or it improves your standing in the community. The weird thing about altruism is that it doesn't seem to do any of those things, yet you see the behavior in non-human species as well as insects. And if altruism didn't do something to enhance survival then all altruists would be extinct by now. What gives?

This is where I get to refer to an economist---probably the only time we've mentioned economists on the blog even though the few I've known have been pretty terrific people. Robert Aumann and Thomas Schelling developed game theory in order to understand economic cooperation and conflict, but they ended up enlightening human behavior. They used mathematical models to prove that given enough time and enough opportunities for strangers to interact the altruists come out ahead economically the majority of the time. Later researchers showed that the "cheaters" (people who don't sacrifice) eventually get punished by the group by being denied opportunities to interact---no one wants to do business with them.

And finally, now that we have this gee-whiz cool fMRI technique you can pretty much count on the fact that someone somewhere has taken a picture of an altruistic brain in action. One study showed that increased activity in the posterior superior temporal sulcus strongly predicted a person's likelihood for altruistic behavior. (And now that I've volunteered my time to write this summary I can practically feel my posterior superior temporal sulcus glowing.)

So now when someone asks you why you volunteered for that activity that everyone else in the neighborhood is hiding in the attic to avoid, you can say: "Because given X number of trials involving Y individuals there's approximately Z percentage likelihood that I'll come out ahead by doing it." Or you can keep it simple: because it feels good.

Fat Doctor Feeds Her Kid Dog Biscuits!


I've just never heard of kids eating dog biscuits.


Press HERE to read about FD's day.

You Order Salad Like A Shrink

Or: working towards the MNP (see posts below)
Warning-- Plot Spoiler



So I went to see Reign Over Me with the connected Judge and my connected now-13-year-old daughter. I think Carrie recommended it some time ago in a comment on an old post. It was my second attempt this weekend to see The Namesake, the first go around I ended up at The Hoax with my husband.

So Reign Over Me Was a shrink blogger's jackpot. Here's the drift:
Alan Johnson (Don Cheadle) is a dentist, he lives in Manhattan with the perfect wife, the perfect life and two lovely daughters. His job and family define him, he longs for friendship, maybe even adventure, his life is perfect but sterile. In a boundary-violating maneuver bordering on stalking, he lurks outside a psychiatrist's office to bombard her with questions about "a friend" as she leaves her office--he can't hear that he should schedule an appointment, and the poor beautiful Dr. Angela Oakhurst (Liv Tyler) gets question after question.

Enter scooter-riding, unkempt, can we pleeese give him a haircut, Dr. Charlie Fineman, Alan's long lost college roommate and dental school pal. Charlie is a walking talking post-traumatic mess from the aftermath of the 9/11 terrorist attacks in which his wife, 3 beautiful young daughters, and poodle (?) Spider, died in on one of the planes. By day, he compulsively and repetitively remodels the kitchen (--an apology, we later learn, to his wife who's final conversation with him was about the kitchen), by night he plays video games on a giant screen, goes to Mel Brooks flicks, collects vinyl from the 70's and 80's. He remembers nothing from before 9/11, has written off his in-laws, given up dentistry, doesn't recognize roommate Allan who reminds him how he used to sleep naked. Oh, good, another penis on the blog; hold on, there's more.

The two re-connect, their relationship becomes meaningful for both of them, their needs almost palpable. Charlie, however, has this little quirk that when someone mentions his past, he gets violent. Oops. Alan, however, is kind enough to overlook a few big outbursts, even one where Charlie grabs him by the neck, slams his diplomas to the wall. And Alan decides that Charlie needs help and he's going to be the one to get it for him.

So Alan has this other little sub-plot problem: a gorgeous patient, Donna Remar (Saffron Burrows) offers him a blow job (see, I told you, more penises), he tosses her from the office and she's sent off with orders to get a new dentist. Only jilted, she then sues him for sexual harassment, ridiculous, but how does one prove what goes on behind closed doors? Office partners just aren't happy. Eventually, he agrees to see her and she apologizes, explains she was mistreated by her ex, drops the lawsuit, turns out to be a patient of the lovely Angela, and will eventually be cast as the will-be girlfriend of the traumatized and violent Charlie the former Dentist.

Okay, so Alan wants to get help for Charlie, who wants no one and nothing that will touch on past memories. In a record store, they bump into the nerdy Nigel who invites them to join them for lunch-- Charlie quickly sniffs out the deception and yells over lunch "You're a shrink, you even order salad like a shrink." A man close to my heart, Nigel responds, "How does a shrink order salad."

Next, Alan introduces Charlie to Angela, who Charlie agrees to continue seeing, in part because she has great breasts, something he doesn't hesitate to tell her. He talks for a few minutes then ends each session abruptly. Finally, Angela confronts him with the fact that he needs to tell his story to someone or there's no point coming. He leaves, and tells his tragedy to Alan in the waiting room as Angela listens. It's one of those tear- jerking breakthrough moments that one hopes will lead to a cure, or even the end of the movie. But Charlie goes home, loads a gun, ends up pointing it at a police officer (this, my real-life judge friend tells me, is called Suicide By Cop), ends up tackled and spending 3 days in a psych unit, where Angela and Alan lobby for his release, and Angela insists what he needs is outpatient care which she can provide-- and ohmygosh nobody mentions that her last great intervention just days before nearly got the patient, or a cop, killed. Charlie goes free, there is another hearing a few days later in which the judge (Donald Sutherland) decides that his in-laws can dictate if he needs further inpatient commitment for up to a year, warning them harshly, "think about whether your little girl would want her husband to go to a place like this." Give me a break.

So Charlie moves out of the apartment with the now gorgeous kitchen, Angela the shrink and Donna the sexually harassing patient bring him root beer and pizza, everyone lives happily ever after.

So PTSD Adam Sandler style, with lots to think about, and while Dr. Angela is actually pretty good at times, there are all the boundary-blasting usual shrink things we've come to know and love in the movies.

Sunday, April 15, 2007

E.R. Call

Panda Bear MD poses the following ED scenario for an on-call orthopedic specialist:

“Good morning, Dr. Smith. Sorry to wake you up but this is Dr. Bear at the County Hospital Emergency Department. I’ve got a 25-year-old gentleman, snowmobile versus barn, with an open mid-shaft fracture of the left femur but otherwise without significant injuries. We have him in a traction splint and his distal pulses and sensation are intact. On the way through the barn he dragged the end of his broken femur through approximately fifteen feet of cow manure and I’m afraid it was about thirty minutes before his drunken friends decided that he probably wasn’t going to walk it off.”

“How’s he doing now? Fine. He’s fully alert and oriented and threatening to sue everybody in the place. Can you come in and see him?”

Would you come in? It is easy to come up with a similar scenario for psychiatry. Yet, it has been a long time since psychiatrists gave up on ERs. I don't have figures, but I'd wager that it is not easy to find an ED where a psychiatrist evaluates the guy with the overdose or the woman with new-onset paranoid auditory hallucinations. More often, they have social workers evaluating these patients. The problem is, many of these patients are better served with a physician with psychiatric expertise, as a good percentage of these folks have medical problems which are dressed up as "psychiatric problems"... things like steroid psychosis, metabolic encephalopathy, and drug-induced syndromes.

Hospitals are increasingly paying specialists to be on call, recognizing the increased risks of treating ED patients, many of whom lack insurance and regular medical care. That includes psychiatrists. The hospitals are now able to see the savings in terms of improved patient flow, higher quality care, reduced liability, and lower length of stay, when using ED psychiatrists. The trouble is finding docs who are willing to take on this lifestyle. Psychiatric hospitalists are starting to crop up more, as they tend to work shifts (eg, 8a-8p), have staggered work days (eg, 5 days on, 4 days off), and get benefits. These are primarily consultation-liaison psychiatrists (like me). Any of you CL docs out there, let us know about any ER call you do.

Saturday, April 14, 2007

Human Sacrifice in Ancient Moche Culture


My Three Shrinks (along with a high school English teacher friend of Dinah's) went to a lecture today at the Walters Art Museum entitled "Human Sacrifice, Power, and Ritual in Moche Society and Visual Culture," by Prof. Steve Bourget.

This was a nice thing to do on a Saturday afternoon. He started out with a picture of Freud, and a quote from him, which said something to the effect that 'sacrifice is the cornerstone of the creation of society'. Before long, we were treated to pictures of pottery and other archeological findings depicting the South American Moche culture (~450-700 A.D.), which included human sacrifice as part of their beliefs, and also as a form of social control.

As depicted in the image above, you can see two fellas at the bottom with their blood being drained from their neck by tribe elders, dressed in various animal-like garb. The blood is put in a cup, which is being passed around the gang at the top. It is not certain whether the blood was drank, but it was used to pigment various pieces of artwork.

Here's the interesting thing. Various lines of evidence points to the conclusion that the Moche sacrifices were used as rituals in response to El Nino-related changes in weather and ocean conditions.

Makes me wonder how much of what we are doing to reduce carbon emissions amounts to ritual sacrifices to increase the perception that we are in control of Mother Nature's ecological cycles.

What's it have to do with psychiatry? I'm sure you can find something in this (I didn't even mention all the penises and the talk about the role of men ("domesticated dogs") and women (a "wild" quality due to their menstrual cycles, which may have been linked to lunar cycles).

It's A Tough Job But Somebody's Gotta Hew It

Human Sacrifice, Power, and Ritual in Moche Society and Visual Culture

[Note: Roy beat me to this topic by a few mere seconds.]

My fellow bloggers are such good friends. They didn't even blink when I invited them to go to a lecture on human sacrifice with me. It was fascinating. The speaker, Steve Bourget, worked for several years on an archeological expedition in Peru involving the Moche people who practiced human sacrifice from 200 to 700 A.D.

Human sacrifice was used to reinforce the political power of rulers by linking them with gods and the priest caste who led the sacrificial ceremony. The victims were prisoners-of-war, sometimes hundreds at a time, who were led nude to the ceremonial site. They were killed by blunt head trauma using a club-like tool or by throat laceration. Many murals and other forms of Moche artwork depicted the killing as being done by humans dressed like animals (foxes or feline characters---like Tony the Psycho kitty?) who would collect the blood in a cup and pass it to the ruler god-figures. The corpses of the victims were defleshed and the skeletons were laid out symmetrically in patterns that seemed to hold some unknown meaning for the culture. Bourget theorized that the sacrifices were used to reset the natural order of the Moche world, particularly during times of heavy El Nino storm seasons when mud would flood the temples and the seas would team with creatures not usually seen in the region.

And then there was the penis issue. (C'mon, it's a psychiatry blog. You're going to see the word 'penis' eventually.) All of the sacrificial victims were men who were depicted on ceramic ceremonial vessels and on murals as being led to the slaughter with erect penises. Guys, correct me if I'm wrong but I would expect imminent death to be a bit of a challenge to the performance issue. I'm guessing the pottery artists were taking a bit of license here. Anyway, after the sacrifice the pottery vessels with the victims' depictions were broken and the fragments scattered about the burial site. The only parts of the vessel left intact were the little pottery penises. Being good academicians, these were counted and reported as the MNP (minimum number of penises) for each archeological site. Roy seemed particularly fascinated by this. Dinah and I were too busy chortling.

Women were nowhere to be seen anywhere in the sacrificial scenes or ceremonies. Bourget explained the female role was largely featured in the fertility iconography, which made sense. We didn't stay through the whole question-and-answer session to learn if this involved any little ceramic breasts.

So that's how we spent the afternoon. I'm grateful to my friends for sacrificing their time to be with me. Especially Roy. After today I think he may not mind being under the floorboards with all of his ceramics intact.

Ladies' Night Out

Or why I don't do custody cases anymore

A friend of mine desparately needed a night out on the town recently so last night we did it, a group of us each in our own various stages of life. I heard about past marriages (or more than one) current boyfriends, behaviors that make up the "why" in the Y chromosome, children, teenagers, laundry and discipline (or lack of it). By the end of the evening I came home feeling somewhat guilty that my life was so peaceful and relieved that I just didn't have to deal with any of that.

It brought back memories of doing court-ordered child custody evaluations. Keep in mind that over the years I've interviewed and worked with psychotic killers, rapists, drug kingpins, death row inmates, mafia figures and various other low-level criminal types.

I'll take them any day over a disgruntled non-custodial parent. Now, most divorces don't end up in court-ordered custody evaluations. The majority of people with kids split up, talk (or shout) amongst themselves and generally figure out what they need to do and when to do it without any court involvement other than a rubber stamp. Those weren't the cases I got. By definition, by the time a case came to me the couple had already been through one hearing, or three, as well as emergency motions for visitation and/or custody, domestic violence petitions, protective orders, social services investigations and/or criminal charges. These were not easy cases.

Over time I learned that all the allegations back and forth could generally be boiled down to four or five categories: allegations of abuse or neglect (physical or sexual), drug use, domestic violence, mental illness or something I call generic "lifestye differences". Non-custodial Mother alleges that Father dresses Daughter in age-inappropriate clothing so she looks like a "biker-chick" while Custodial Father complains that Mother wants Daughter in black patent leather shoes with white anklets. Or Mother alleges that Father is a lying psychopath with sexual interests in their teenage babysitter. Or Father really has been convicted of multiple felonies and the interview alone is enough to get you thinking about the distance between yourself and the nearest security alarm.

In memory of Kurt Vonnegut: So it goes. One must fight the temptation to toss the child to the nearest passing stranger.

The fathers I interview assume that because I'm a woman I will naturally side with the mother. The mothers assume that because I'm a woman I will naturally agree with their childrearing tactics and the fact that all men are rats. And they all want to know whether or not I have kids. (I don't.) Being childless is an advantage in these situations. I am not saddled with my own personal shtick of past marriages (or three), domestic violence and childrearing issues. And if being a biological parent had anything to do with good parenting skills we wouldn't need these evaluations to begin with.

The children are the most honest ones of everybody involved in the litigation. My ears would always perk up at any sentence out of their mouths that began "My mother wanted me to tell you..." They were honest even about their coaching. I was also surprised by some of the things the parents admitted: quizzing a child in detail about the other parents' sex life, plans to take the child and run, attempts to undermine the child's medical or mental health care. Sometimes the main goal of the evaluation was just to make sure the child didn't disappear or die in the process of growing up.

The fact of the matter is that there is no litmus test for being a good parent. In spite of the thousands of dollars being paid (to private forensic evaluators, not the court-employed folks) for interviews and psychological testing, no psychological test can tell you which parent is best for which kid. And the answer may be different for each individual child even when the same parents are involved. A child who is unpredicatable, emotionally labile and impulsive may do best with the parent who is patient, stable and consistent while the shy, slow-to-warm-up child needs an extroverted parent. Regardless, most kids are pretty resilient and they grow up to be normal responsible folks in spite of the craziness between their parents. I just hope they manage their own custody issues as well when they're adults.

Thursday, April 12, 2007

15-minute Med Checks


I noted in today's Northern Star that Dr. Diana Kraft, Northern Illinois University's psychiatrist for 15 years, has retired after being told she must cut back on the amount of time she spends evaluating patients. The side bar in the paper indicates:

"On March 8, Kraft was notified by her supervisor that the time allotted for her to see patients would be reduced from 60 minutes for a new patient to 45 minutes, and 20 minutes for a return patient down to 15 minutes. Incorporating paperwork and dictation, Kraft would only be allotted 30 minutes of face time for a new patient and 10 minutes for a return patient, she said."
I hate it when administrators see patient care as an assembly line which can get speeded up when demand or profits require more efficient widget production. People are not widgets.

Wednesday, April 11, 2007

On Being Connected


This is a post that's about me and my life and something that's important to me, and it's about psychiatry, even if it might not seem that way.

I am very lucky. I have some really wonderful people in my life--both family and friends. My husband and I met our freshman year of college-- we've been together our entire adult lives, we carry each others' histories, we've shared nearly every event (including and especially the Red Sox victory in the World Series in 2004, even if he was in a hotel room in Florida), he knows all the inside jokes, let me write chemistry equations all over his legs, listened to my pre-med then med school angst, has survived endless shrinky dinner parties (--newsflash: he's not a doc).

And then there's the Judge, along with her dog Tex (who vomited on my carpet this morning, thank you for that Tex), who makes her way over for coffee every morning, still in juice-can sized hair curlers and looking very lovely nonetheless. Every morning you say? Every morning. Occasionally, wine later in the day, once she called from her car to ask if I'd go out for soup with her (I did) and the Judge is always up for a movie, so my standing date to chick flicks. I like Carol (and doggy Prize) and Maria (and Nelly who jumped on my bed, tracked mud through the bathroom, & ate the garbage) too, but they're more sporadic and I often hear about their lives in snippets, not as a continuous episode.

Camel (see my post: Everyone needs a Camel) lives pretty far away, but we talk often, sometimes daily, always on the go, sometimes for pretty long. We talk about psychiatry, the hubbies, the kids, whatever. My first stop when I have a problem that needs solving. Camel has good ideas and another minor bonus about her: very good taste in food-- when we're in restaurants together, sometimes I just order whatever she's having because hers is always good.

ClinkShrink has ragged on me for 20 years now, she's in my life more since the blog (this is good). Mostly though, I remember that residency wasn't always the easiest time for me-- I was new to Baltimore, soon pregnant, missing my friends and feeling a bit isolated, as well as exhausted. There were times there I called Clink every night, for long periods of time. She talked about her cats (Spike, then Elavil and Prozac, I kid you not). It was nice. It's probably taken me 20 years to appreciate just how nice.
Linda from med school writes in frequent spurts, glimpses of her life as mother and shrink (in that order). She listens to some of the garbage that courses through my mind, stuff I'm happy to have someone a little bit at a distance to tell these things to.

And then there's ABF. Where do I begin? She sat in front of me in Mr. Wasserman's civics class in Junior High. We lost each other in college-- she sort of fell off the map right after she visited me during a break our sophomore year. I next heard from her 10 years later, and again, 10 years after that. And then came e-mail, and when ABF got email-- maybe 2 years ago?, we started sharing our lives. Again. We took off from somewhere new, it's not just where we left off, and we email, everyday, probably 3 times a day. We've caught up on the past, I think, shared our views on religion, child-raising, weight loss efforts, what we're having for dinner (yes, this is what psychiatrists talk about with their friends, it's a step beyond the endless junior high school discussions about pierced ears and shampoo). ABF has two children, a son with autism, she spent today helping her daughter with her Spanish class project, she knows what I did today and every day. She's getting over a cold, tea and chicken soup have helped, and the weather in Boston has been quite cold lately. I go through my days filtering my experiences with the thoughts that "Oh, I'll tell ABF that later." I've only seen ABF once in recent years, it's funny that this relationship of bits-and-pieces of the mostly mundane, is so important to me.

I forgot some others-- some of my email relationships have been very meaningful to me, but have petered out at least in their day-to-day investment. Cuz B used to write several times a week, I knew when she took a walk, when she had her hopes up about an audition, when a boy was on her mind. Now it's down to once a week, we skim over some of the little stuff, she's still huge in my heart. Victor has made his way in, and now has been dragged to hear a psychoanalyst speak on the most depressing of Russian films. Roy, of course, is special, a friend I connect with on perhaps a different level; I think he wants me to appreciate Monty Python and it may be a climb. Eight years of lunch with Lisa on Monday-- friendship contained in its own little box-- and I still miss her.

When my mother was alive, she cared about my life in the most detailed way. She lived a few hours away, I didn't see her often, but who else cared so much about the little things. If I bought a new shirt, who else would ever ask me to describe it in detail? After she died, I wished I'd had a digital camera so I could have photographed and e-mailed her the smallest of things, she liked to picture everything in her head.

The blog is like it's own little world-away-from-reality of connection. The same people visit and reliably post. I wonder how Foofoo5 is doing. Carrie, Midwife With a Knife, and Lily come daily, Sarebear wanders in and out, JCAT, Rach, and the assorted others who touch our bloglives at particular moments when something resonates.

So I said this would have something to do with psychiatry, not just my personal ramblings. Today my youngest turns 13, I think I'm feeling a little sentimental. My husband and I were talking about plans for the day, I referred to her "the baby" as I often do, and he said, "She's not a baby anymore." Oh, she still is.
-
Obviously, psychotherapy is a way of being connected. Someone listens, they listen hard, they care about the details of your life, they remember them week to week or month to month, they want to know what happens in the next chapter, in a sense they collect you. Maybe it's love, in some funny sense of the word, certainly it's intimacy, sometimes it's simply a business affair. Hopefully some of it's about mutual caring.
-
There, did I tie it together?

Monday, April 09, 2007

Caroline Reads The Blog!




I was invited to Caroline's on Easter Day for wine, appetizers, and an egg hunt. It was a lovely event, a bit chilly, but they had an outdoor fireplace going. So I'm talking to Caroline--whom I haven't seen in months (people here kind of hibernate in their caves during the winter)--- and she starts telling another person about Shrink Rap! She was even quoting different posts. Wow! I didn't remember that I'd ever told Caroline about the blog, I found myself vaguely embarrassed, but ultimately quite flattered.

Caroline Reads the Blog!!!
(Please note: the photo above shows ClinkShrink and Roy, not Caroline)

Pinching Pennies, Counting Costs


This is just a quick post to put up a link to an article I just stumbled over about the cost efficacy of mental health courts. It's the first data to be published about this and it just came out this month. The first link is to the summary, the second link is where you can download the Rand Corporation's full report.

They basically report that for the one mental health court that was studied the costs of treatment versus incarceration break even over the two year study period. The jail costs declined, but the treatment costs increased to offset it up until the last two quarters of the two year study period. There was an overall cost savings in the final two quarters that was statistically significant. There was no increase in risk to public safety (no surprise there really since these courts usually don't take violent offenders).

My Three Shrinks Podcast 15: POTUS Reading


[14] . . . [15] . . . [16] . . . [All]

Just want to say Happy Easter and Happy Passover to those of you who celebrate either.

April 8, 2007


Topics include:
  • Q&A: from Gerbil, who asks, "I'd love to hear your thoughts on treatment contracts. My specialty is self-injury, and I often give talks on this subject. Invariably, at least one of my attendees will share that he/she has clients agree that they will be discharged if they hurt themselves between sessions. I've heard others talk about making similar contracts regarding substance use, gambling, and other high-risk behaviors. This makes no sense to me--why make the goal of therapy the condition for receiving therapy? ... I was interested in your opinions, especially because of the settings in which you work."

  • Dinah rants about Insurance Companies.
  • Article on Mentally Ill Presidents from Mental Healthworks Newsletter. Nearly half have had mental illnesses. This leads into a discussion about the validity of doing psychological autopsies, or diagnosing someone without personal examination. The Goldwater Rule is discussed in this context (re: Presidents of The United States, or POTUS), as are the APA's Principles of Medical Ethics.
  • Who Reads Shrink Rap? Reader Poll Results: 20% are physicians (13% psychiatrists, 7% others); 9% nurses; 7% social workers; 7% psychologists; ~30% patients; and ~30% others. So more than one-third are mental health professionals, and close to one-half are health care professionals (nearly 200 readers voted).

Find show notes with links at: http://mythreeshrinks.com. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening.

Sunday, April 08, 2007

FDA Drugs: February 2007

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

FDA Drugs: February 2007

  • Warning Letter: Signature Genetics. Seryx is the company that markets an excellent (but expensive) pharmacogenetics program which will take your blood or cheek cells and analyze your DNA for various genotypes which affect how your body metabolizes certain drugs, many of which are psychotropic drugs. This information may be used to help a prescriber make decisions about starting dosages or drugs or combinations of drugs to use or avoid. This topic is a whole 'nother post I could do, but this type of testing can be used inappropriately (2002 Quackwatch page), as well. Anyway, this computer program is considered by the FDA to be a "device", and it has not applied for FDA approval, so the FDA is telling it to stop until approval is obtained.
  • Wellbutrin (bupropion) Medication Guides updated: PDF versions of Medication Guides for Wellbutrin and Wellbutrin SR were updated.
  • Generic Focalin (dexmethylphenidate) approved.
  • Only 22 New Drugs Approved in 2006: Merrill Goozner comments on his blog, GoozNews, about the lowering of innovation in the pharma industry.
  • FDA Starts Podcasts: The FDA Commissioner, Dr. Andy von Eschenbach, has started a series of drug safety-oriented podcasts. The first one just announces the series. Go to the XML feed to subscribe.
  • ADHD Drug Warnings: The FDA is requiring all manufacturers of drugs used to treat ADHD, including Adderall, Concerta, Ritalin, and Strattera, to develop Medication Guides to warn patients about the risks of cardiovascular (sudden death, stroke, heart attack, blood pressure) and psychiatric (mania, psychosis, aggression) side effects.
  • Vyvanse releases Medication Guide: Shire's Vyvanse (lisdexamfetamine dimesylate) was listed last month (before the name was changed from Vynase) as a new ADHD drug. It is a prodrug, meaning it is metabolized into an active drug by the body. Advantages are said to be that it is once-daily and that it is less likely to be abused (ie, 4 out of 5 drug abusers prefer other stimulants to this one). It now has full approval as a Schedule II drug (for full prescribing info, see link to Label Info here.)
  • Changes in Nardil (phenelzine) Prescribing Info: added severe renal impairment or renal disease to list of contraindications; added cautions about use in diabetes; and added warning about drug interaction with guanethidine (Ismelin).
  • Changes in Cymbalta (duloxetine) Prescribing Info: a number of changes were made, though I cannot tell how substantive these were. Lilly did receive a new indication for the treatment of GAD (Generalized Anxiety Disorder) with Cymbalta.
  • Changes in Effexor XR (venlafaxine) Prescribing Info: the following was added under the Precautions section: "Interstitial lung disease and eosinophilic pneumonia associated with venlafaxine therapy have been rarely reported. The possibility of these adverse events should be considered in venlafaxine-treated patients who present with progressive dyspnea, cough, or chest discomfort. Such patients should undergo a prompt medical evaluation and discontinuation of venlafaxine therapy should be considered."
  • Zimulti or Acomplia (rimonabant) review extended: This cannibinoid receptor antagonist, which is being reviewed as a weight loss drug (you guessed it... it blocks the munchies, even if you are not smoking pot), was to have a final decision on approval status on April 26. The review period has been extended to July 27. (I reported in November's update that this drug was approved in Mexico.) The latest proposed brand name is Zimulti. The hearing for this drug will be held on June 13, 2007, before the Metabolic & Endocrinologic Drugs Advisory Committee. When the background resource documents are ready, they will be found here.
  • Warning Letter: Provigil (modafinil). Cephalon got slapped for promoting its wakefulness-promoting drug (indicated for use in narcolepsy, obstructive sleep apnea, and Shift Work Sleep Disorder) by distributing a document by Dr. Kerasidis which states the drug is effective in multiple sclerosis, Parkinson's, depression, ADD, and chronic fatigue syndrome. Interesting, in that this document was provided as testimony to the Maryland Dept of Health and Mental Hygiene's Committee which is responsible for making decisions about which drugs will be placed on the Medicaid formulary list.