Saturday, December 31, 2011
Sunday, December 25, 2011
Best wishes to our readers, listeners and followers. May you have peace, blessings and good health now and in the New Year.
Saturday, December 24, 2011
This is an eye-opening essay about how lobotomies were used back in the day.
[posted via email]
From The New York Times:
ESSAY: When Lobotomy Was Seen as Advanced
New research indicating that Eva Perón was lobotomized not long before her death is a reminder of how enthusiastically this operation was once embraced.
This is a great story about turning around ones life with addiction and mental illness, giving back by training others to do peer counseling, which is such a proven strategy that Medicaid will pay for it.
[posted via email]
From The New York Times:
LIVES RESTORED : After Drugs and Dark Times, Helping Others to Stand Back Up
The mental health care system has long made use of former patients as counselors, like Antonio Lambert, an ex-convict turned mental health educator in Delaware.
Thursday, December 22, 2011
Happy Holidays, everyone. We taped this a few weeks ago, but Shrinky Podcasts always make for good holiday chatter. Today we talk about
1) Brain Freeze-- inspired by a Well article in the NYTimes for 11/10 on Rick Perry's Brain Freeze. You'll note that in this podcast, Dinah reads Roy's mind, and no has brain freeze from eating cold ice cream. We kind of ramble, and so what else is new? We talk about memory and attention and learning and Dinah explains why men don't take out the garbage during football games. Clink talks about the scientific phenomena of "brain overload."
2) Siri-- ah, we did this podcast right after I got my new iPhone and it was new and exciting and I was working on an article on Siri and the Psychiatrist. We ask Siri where we can buy a duck and when the world will end. Apparently we have 5 billion years. And Sigourney Weaver was 62 years, 1 month, and 5 days old at the time we recorded.
3) Prison Food-- inspired by a lawsuit in which a prisoner contends that the soy-based food being served in prison is 'cruel and unusual punishment' which caused him cramps. Clink talks about how prison food is handled. She also talks about nutrient rich Nutraloaf that can be eaten without utensils and she discusses an NPR story which includes the recipe for anyone who would like to try nutraloaf.
If you'd like to try it:
Special Management Meal
Yield - Three Loaves
• 6 slices whole wheat bread, finely chopped
• 4 ounces imitation cheddar cheese, finely grated
• 4 ounces raw carrots, finely grated
• 12 ounces spinach, canned, drained
• 2 cups dried Great Northern Beans, soaked,
cooked and drained
• 4 tablespoons vegetable oil
• 6 ounces potato flakes, dehydrated
• 6 ounces tomato paste
• 8 ounces powdered skim milk
• 4 ounces raisins
From Clink: You mispelled nutraloaf. Don't worry, I fixed it. Also, by pure coincidence today's correctional nursing topic on Lorry Schoenley's Blogtalk radio show was all about managing food allergies in corrections. For those of you who want to know what happens to inmates with peanut allergies, here it is directly from someone in the know.
Thank you for listening.
Tuesday, December 20, 2011
We've talked before about whether people with mental illnesses can be politicians (or pilots, or doctors). Today, on Midday with Dan Rodricks on WYPR, psychiatrist Nassir Ghaemi, author of A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness makes the case that in good times, we need sane and stable leaders, but that in difficult times, "insanity produces good results" and that in hard times those with mental illness are better leaders. He talks about how mood disorders lead people to be more realistic, empathetic, resilient, and creative. Want to hear more? Click HERE to listen.
Kind of nice to hear a positive take on psychiatric disorders for a change. Tell me what you think.
Sunday, December 18, 2011
Before I begin, I wanted to let you know that ClinkShrink wrote a post called Can You Tame Wild Women? over on our Shrink Rap News blog this week.
When we talk about psychotherapy, one aspect of what we look at is the process of what occurs in the therapeutic relationship. This is an important part of psychodynamic-based psychotherapy, meaning psychotherapy that is derived from the theories put forth by Freud. Psychoanalysis (the purest form of psychodynamic psychotherapy) includes an emphasis on events that occurred during childhood, and a focus on understanding what goes on in the relationship between the therapist and the patient, including the transference and counter-transference.
In some of our posts, our friend Jesse has commented about how it's important to understand what transpires in the mind of the patient when certain things are said and done. Let me tell you that Jesse is a wonderful psychiatrist, he is warm and caring and attentive and gentle, and he's had extensive training in the analytic method, he's on my list of who I go to when I need help, so while I want to discuss this concept, I don't want anyone, especially Jesse, to think I don't respect him. With that disclaimer.....
On my tongue-in-cheek post on What to Get Your Psychiatrist for the Holidays, Jesse wrote:
When I say the Shrink should look at the context, even in small matters a gift might come with a subtext: "I just told you some terrible things about me and I want to be sure you still like me." It can be a bribe. It can be a seduction. It can simply be a gift given out of gratitude. The important concept is that we think about everything. Unlike a physical examination done by an internist, everything that occurs might be some window into how we can help the patient, and we do not want to lose that opportunity.
So wait, the patient comes to me because he symptoms of a mental disorder, often depression or anxiety, or problems controlling his behavior, or he's overwhelmed with stress and isn't coping well. Why is it so important that we understand every aspect of the sub-texted interactions? How does this cure mental illness? Why is it bad to accept (or not) a gift and move on? Why do we have to think about everything? And if it's really important, won't it come up again? Is it really crucial that we not lose that opportunity? Maybe I just want to take the cookies and say 'thank you' because
- A) I don't want to hurt my patient's feelings,
- B) it can be difficult to look at the meaning without upsetting the patient or putting the patient on the defensive and so the patient has to be fully on-board for this type of therapy and those patients generally don't bring gifts (ah, maybe we should be asking all analytic patients why they didn't bring gifts, now that might yield interesting information), and
- C) I like cookies.
Just so everyone knows that I am still Jesse's friend, I am posting the video he sent me of his late grand-chinchilla, Chinstrap. And yes, Jesse had a grand-chinchilla. He does assure me that Chinstrap was having a good time in this video, because I wondered.
And I'd like to thank Steve over at Thought Broadcast for providing the graphic for today's post.
Friday, December 16, 2011
Playing with Pigs: Pig Chase from Utrecht School of the Arts on Vimeo.
I want this game. A company in the Netherlands is working on an iPad app that will let people interact remotely with pigs on a farm. Apparently pigs like to interact with bright balls of light. This app creates bright spheres of colored light on a panel in a pig sty. The pig touches the light with his snout, which scores a point. The number of touches racks up a score, and at the end of the game the high scores get displayed on the iPad. I'm not sure if the human is training the pig to touch the screen, or if the pig is training the human to play longer with an iPad. Either way, it looks like a lot more fun than Angry Birds.
Here's the web site for the video:
Playing With Pigs
And the other amazing thing is that we already have a "pig" label on the blog. Have we really talked about pigs here before?
And for Jesse, a hamster:
And here's one from Roy with ants...
Tuesday, December 13, 2011
Facebook is launching a new suicide prevention chat hotline for those who post worrisome comments on their walls. From an article in Newsday:
Here's how it works:
A user spots a suicidal comment on a friend's page. He then clicks on a "report" button next to the posting that leads to a series of questions about the nature of the post, including whether it is violent, harassing, hate speech or harmful behavior.
If harmful behavior is clicked, then self-harm, Facebook's user safety team reviews it and sends it to Lifeline. Once the comment is determined to be legitimate, Facebook sends an email to the user who originally posted the thoughts perceived as suicidal. The email includes Lifeline's phone number and a link to start a confidential chat session.
The recipient decides whether to respond.
Facebook also sends an email to the person who reported the content to let the person know that the site responded. If a suicide or other threats appear imminent, Facebook encourages friends to call law enforcement.
Sunday, December 11, 2011
For a while now we've been talking about issues related to psychiatry and electronic medical records. Roy is very interested in the evolution of EHR's.
I don't like them. I think they have too many problems still, both in terms of issues of efficiency and time, and how they divert the physician's attention away from the patient, and they focus medical appointments on the collection of data-- data that is used in a checkbox form: patient is not suicidal and I asked, whether it was clinically relevant or not-- and will therefore serve as protection in a lawsuit, or demographic information used by insurers, the government, who knows.
From a privacy standpoint, I think they are appalling. If you are a patient in the hospital where I work, you get no say, your info goes in to the electronic record and everyone who treats you can access it. And anyone else who uses the medical record in the hospital can access it as well; the "check" on the system, since much of our city is treated at this hospital, is the after-the-fact threat/fear of being fired or disciplined for looking at someone's record you shouldn't. I believe the check should be before the fact-- that a patient should have a code, or PIN number they punch into the system that unlocks the system for that particular healthcare provider. Or something akin to that.
But what about the fears that people express on our comments that they will be judged and dismissed if their doctors know they've seen a psychiatrist or taken a psychotropic or been hospitalized? On one hand, there is the idea that this information is more sensitive and should be protected, so that psychiatry records have traditionally been kept out of EHRs. On the other hand, there is the belief that calling them "sensitive" further stigmatizes psychiatric disorders and it's time to treat them like every other medical problem.
I will tell you that last year when we did a survey of Attitudes Towards Psychiatry, 41% of respondents thought psychiatry records should not be segregated.
Electronic Health Records (EHRs or EMRs) . . .
People may select more than one checkbox, so percentages may add up to more than 100%.
Thursday, December 08, 2011
In yesterday's post on e-prescribing, the issue of patient confidentiality came up in the context of doctors being able to see a patient's full medication history in an electronic program, and one commenter brought up that she doesn't necessarily want to tell her shrink about a yeast infection, perhaps because she finds it embarrassing. The writer of the post, a guest blogger, suggested that this might lead to useful information that should be addressed in therapy, for example the patient's sexual life.
Years ago, I remember being a bit taken back when a patient brought up some rather problematic (to him) sexual issues in his marriage. It wasn't the nature of the issues that surprised me (I spent more than a decade consulting to a sexual behaviors unit and I spent several months of residency training on an inpatient sexual disorders unit: it takes a lot to shock me). What surprised me was that this was the first I was hearing about this issue after seeing the patient for 5 years of psychotherapy. He had a secret life.
There's not really much to do about this. One can only help people with the things they bring forward as problems, and we don't, as one commenter pointed out, get notified by the bars every time a patient drinks, or doesn't exercise, or begins yet another dysfunctional relationship, or surfs over to a porn website. Oh, and I am so glad.
When it comes to hiding medications, or treatments, then perhaps that's different. Is it okay for a patient to see one doctor for a Xanax prescription, and if he's not happy with the dose, to see another doctor for more Xanax? If he's not selling it, I don't think this is illegal, but we'd (meaning docs) all agree that this is wrong, that the patient is deceiving us, and wouldn't prescribe to someone doing such things. Is it okay for a patient to hide the fact that he has AIDS, a condition with known psychiatric complications, from his psychiatrist? We might say that if we're not aware of the medications a patient is taking, then we can't be liable for the interactions, but please-- in therapy it's not just about the fears of lawsuits between strangers, it's also about not wanting to see your patient get sick for completely preventable reasons.
So where is the line? Is it okay to hide manic behaviors from a psychiatrist---it's none of his damn business if I wanted to sleep with 8 gorgeous women last night and buy them all diamond rings! Is the psychiatrist entitled to know every behavioral transgression? That he's worth millions when he's getting a discounted fee from the shrink? That mom thinks he's getting sick again? Every fantasy that pops into his head? Is it okay to withhold your dreams from your psychoanalyst?
I won't go on. You tell me where the exact line is. I have no idea.
Wednesday, December 07, 2011
Over on our Clinical Psychiatry News website I'm writing about my struggles with electronic prescribing. The post, "To E-Prescribe or Not? That is the Question" will be posted on December 7, 2011. In order to write it, I bothered just about every shrink I know, or it least it felt that way. One of the psychiatrists who was kind enough to respond with a great deal of useful information was Dr. Jeff Soulen, a psychiatrist in private practice, who has had a positive experience. This is Dr. Soulen's first experience as a blogger.
I've been using Allscripts for about 3 years now, and I must say I like it a lot. It's free (no need to sign up for the paid Deluxe version) with a browser-based interface, so I can access it anywhere -- helpful when I'm away from my charts. I pretty much do 100% of my scripts electronically except controlled substances, for which it's still illegal to e-prescribe. What I like about it:
- I see a list of every script my patient has filled, including those from other docs, though this information is sometimes spotty. It's led to some important discussions about controlled substances I didn't know the patient was taking, drugs that have interactions with the ones I'm prescribing, etc. Kind of wondrous to enter a patient's name, zip and birth date and 5 minutes later the whole list is on your computer screen.
- Patients love it. Once they are in the system-- which takes a couple minutes the first time-- it takes me no more time to send a script electronically than to hand-write it, and by the time they get to their pharmacy later that day, the script is ready for them - no need to bring a paper script and wait.
- For repeat scripts, it's faster than hand-writing - select from the list of scripts you've sent previously for that patient and send.
- No more transcription errors from a paper or phoned script.
- It's been a huge time-saver in that I no longer get calls requesting refills of scripts where I wrote refills, but the pharmacy in their rush put 'no refills' in their computer. This used to happen a lot.
- All the mail-order pharmacies seem to be tied-in at this point, so sending mail-order scripts electronically is as easy as sending to a local pharmacy. Way faster than filling out fax forms by hand, then faxing them. And patients seem to receive mail-order meds about 4 daysafter I send an electronic script - significantly faster than faxed or phoned scripts.
It is true that an occasional script fails to make it through the system to the destination pharmacy. So far that's been well less than 1% of the scripts I have sent, and re-sending a script a few times a
year takes much less time than calling patients/pharmacies several times a month to tell them that yes, the original script did have refills on it.
If you want to prescribe from a smartphone, you have to purchase the Deluxe version. I don't know how much that costs.
Bottom line, for my solo private practice it's been terrific -- faster and more accurate for me, gives me information on drugs my patients are taking and have failed to mention, and patients love it. I e-prescribe for all those reasons, not because of Medicare penalties.
If you surfed over to the CPN article, you'll know that my experience with e-prescribing has not been as happy as Dr. Soulen's. Of course you're invited to tell us about your experiences...
Tuesday, December 06, 2011
This is an update of a Shrink Rap post that originally was posted in 2006. Seems like a good time for a re-run.
Sarebear mentioned some time ago that she didn't know what to get her psychiatrist for the holidays. I thought about this and decided the answer is easy:
Give your psychiatrist a holiday card and write something meaningful and kind in it. Say, "Thanks for helping me." Or "I'm glad you're in my life." "You're the best psychiatrist in the world" works nicely, too. If you hate your psychiatrist and for inexplicable reasons feel compelled to get them something anyway, then skip the note and just give a generic Seasons Greetings card.
Don't get your psychiatrist an expensive gift. And don't, not even as a joke, give your psychiatrist money-- unless you're paying an overdue bill-- and don't make comments about a holiday "tip."
So gifts and shrinks are often an unsettling combination. As psychiatrists, we're taught that treatment is offered for a fee. End of discussion and anything more represents a violation of boundaries. Psychiatrists-in-training are told not to accept gifts, and psychotherapists as a whole are taught to try to understand behaviors that skim the usual boundaries. So, theoretically, the psychiatrist should refuse the gift and explore with the patient what meaning the gift, the refusal, the whole exchange, has to the patient.
When residents ask me what to do when patients want to give them gifts, I say "Tell them the program has rules that say you're not allowed to accept gifts." This is the truth and the resident risks getting in trouble if they do accept gifts. If you can't take a pen from a drug rep anymore, why should you be allowed to take a timeshare from a patient? Okay, I made that up, I've never heard of a patient gifting a resident with a timeshare, but we can all have fantasies, right?
I'm in private practice, there's no program director, I make the rules. When a patient gives me a gift, I accept it and say, "Thank you." Why? Because it seems intentionally hurtful to do otherwise-- I assume it has meaning to the patient, that their feelings will be hurt if I refuse the gift, that the patient has taken the time, effort, and money to pick out a gift and this represents something meaningful to him and that it might be painful to have this refused. While the act of giving a gift might have a multitude of meanings, depending on the gift, depending on the patient's illness, depending on the circumstances, I just can't find a way to say No that would feel anything other than rejecting. So I accept the gift and thank the patient, and if the gift is edible, I eat it. This is the thing though: while I've decided that this is the way to go, at least so far for me within the realm of my own practice, I always feel like I'm doing something wrong by accepting a gift. Training issues remain in the back of my head, and I'd really rather just have a card that says I'm the best psychiatrist in the world.
Disclaimer in honor of other non-shrink physicians: Doctors in other specialties have no such concerns with accepting gifts. They probably don't want anything that taxes your budget. Food is usually good, a bottle of wine, a plant, candles, all will do nicely, and no doctor expects gifts from their patients.
Sunday, December 04, 2011
These are the topics we talk about:
The Bystander Effect and why people don't call for help when they see violent crimes. While we don't talk about the events at Penn State, this was the inspiration for this topic.
From this we go on to talk about legislation that has been proposed to make it a crime for health care workers (including shrinks) to not report child abuse. As is, there are mandatory reporting laws and licensing implications for those who do not report instances of child abuse.
Finally, we move on to happier techy stuff and discuss Depression Rating Apps.
Roy reviewed iTunes apps with the keyword "depression" which met the following criteria: Medical category; a rating of at least 3 stars, and at least 100 ratings. Five apps came up:
- 3D brain (9600 ratings: not a rating tool but a nice 3D map of the brain)
- Sad Scale Lite (800 ratings: uses a Zung depression rating scale)
- DepressionCheck (700 ratings: uses a 27-item validated screen for depression, bipolar, PTSD, and anxiety)
- Moody Me (600 ratings: an emoticon-based mood diary)
- Health through Breathing: Pranayama (300 ratings: not a rating tool, but a highly-rated meditation tool)
[Disclosure: Roy has consulted for M3, the makers of DepressionCheck.]
This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com.
Thank you for listening.
To review our book, please go to Amazon.
I'm writing this post because the New York Times has been writing about how thyroid disorders and Vitamin B12 deficiency can be responsible for neuropsychiatric symptoms.
Read the article about Vitamin B12 here.
Read the article about Thyroid function here.
This is news? When I was in medical school, the knee jerk response to memory complaints was to order labs to rule out the reversible causes of dementia: CBC, Chemistry panel, VDRL (syphilis), thyroid function tests, folate and B12 levels, urinalysis, and then perhaps a brain CT.
So let me tell you how a physician thinks about dementia. First let me tell you what dementia is: the decline in cognitive function from a prior baseline, often seen by the patient as memory problems, beyond what would be expected with normal aging.
A patient presents with complaints of memory problems. The physician (usually an internist or primary care doc) takes a history: when did this start, did anything precede it, are things stable or getting worse? What exactly is happening and is the patient actually having memory problems? Sometimes people think they are having memory problems, but really what is happening is that they are anxious or distracted, so the information never makes it into their brain to be retrieved or remembered later. "I told my husband to take out the trash during the Super Bowl and he didn't remember to do it." A quick measurement of memory may be done, such as the Mini-Mental Status Exam, which tests a variety of components of cognition such as orientation, the ability to immediately recall, memory, concentration, the ability to follow directions, and the ability to copy a diagram, write a sentence, and follow a written command. It's a simple test, and most people get perfect scores, and it's a quick way to follow progress over time. A physical exam is done, including a neuro exam, and if there are focal findings --like the absence of reflexes or weakness, or loss of sensation, or a history of loss of consciousness, seizures, or a head injury-- these are noted.
The only way to be 100% certain of the type of dementia is to biopsy the brain. We don't generally do that. Instead, we rule out the "reversible" causes of cognitive decline-- infections, thyroid disorders, neurosyphilis, folate orVitamin B12 deficiency, or metabolic problems such as confusion with markedly elevated blood glucose or neuropsychiatric symptoms with hyperparathyroidism. Some of these illnesses are discovered with blood tests, others require a scan to look for anatomical lesions, like hydrocephalus, stroke, subdural hematoma. If a reversible cause of dementia is found, it can be treated and it will often get better. Oh, and I should add that Major Depression can mimic mild dementia, and this too can be treated, it's called pseudo-dementia and when the depression gets better, the dementia gets better.
If a patient has dementia, and the reversible causes are ruled out, then the diagnosis of depression is based on the features of the disorder and the course it takes. Alzheimers' disease is the most common type of dementia, and it has a progressive course with some predictability. Patients with Alzheimer's disease will have a good recall for past events, but they may forget more recent events. Personality and social appropriateness are preserved until well into the illness, and the early stages are often rather subtle. Decline can take place over a few years or many years, but the course is always progressive. Medicines, such as Namenda or Aricept may be prescribed in the hopes of slowing the course, and patients with vascular dementia may be told to take aspirin to prevent future episodes. While patients have good days and bad days, these illnesses do not remit.
Vascular dementias progress in a more step-wise course. Patients will have a sudden onset of impairment, but things stay at that level for a while, until another event happens and there is another sudden decline. The course is less predictable with regard to what faculties are compromised when. Some patients have both forms of dementia, or a mixed etiology.
Other forms of dementia include Pick's disease (fronto-temporal dementia), Lewy Body dementia, and dementias associated with Huntington's Disease, Parkinson's Disease, and HIV, and dementia due to repeated brain trauma.
Okay, this is my quicky discussion of dementia. Please don't use this as a comprehensive resource, it's mostly off the top of my head. Roy can pipe in with all the things I missed, I'm sure there are plenty.
Friday, December 02, 2011
I stole this video from Thought Broadcast. We are, after all, the Shrink Rappers. I'm not sure who Steve Balt thinks he is posting this without us.
Here's a plug for a new psychiatry blog started by a medical student across the pond, called the Manchester Psychiatric Society.
Over on our Clinical Psychiatry News website, ClinkShrink is talking about whether or not the criminally insane ever get released-- a timely topic as John Hinckley Jr.'s hearing for release continues.
Apparently, my post called No One Likes Me was not quite accurate. There was technical issue over with KevinMD's Facebook counter, but it was fun writing the post anyway.
So like when is Clink putting up our next Podcast??? Do feel free to nag her.
Wednesday, November 30, 2011
If you check out the today's posts over on KevinMD, you'll notice that Kevin picked up my post on the ethical dilemma of the college student and the internship application. You'll also notice that the post was tweeted 37 times, and that no one "likes" it on their Facebook page. The story on the Therapeutic Value of Touch got 56 "Likes" and the Art of Alzheimer's got 26 "Likes." My story is alone in it's unlikability.
And now that you mention it, our posts on Shrink Rap don't have many Likes and our fan page doesn't have very many fans/friends.
You know, I would take it personally, but when we first put the page out, one of our readers mentioned that if they "Liked" a psychiatry book, all their friends would see and would wonder why. Is it true? I don't think too hard about what other people "Like" but for the non-stop political stuff. But then again, I have a socially acceptable reason to "Like" a Shrink Rap book (--I think, my kids would probably say it's bragging to like your own book). So maybe people don't "Like" shrinky stuff because they don't want to worry about the message it sends and the questions this might open, either aloud or in the viewers head. Or maybe I just write boring stuff and this is my way of defending my ego against demoralization.
Just in case you're wondering, 262 people "Liked" my Analysis of the Angry Birds addiction when it was posted on KevinMD. Maybe that was a safer "Like." But who's counting?
Tuesday, November 29, 2011
Saturday, November 26, 2011
Earlier, we were talking about an ethical dilemma in The Very Badly Behaved Health Care Practitioner-- What should a therapist do if he's treating another therapist who confesses he's been having an affair with a patient? Should the treating therapist report his patient to their respective licensing board? Of course, the comments are the most interesting part of that post.
It got me thinking about two things: Doctor-Patient Confidentiality and What is a Patient?
From the Encyclopedia of Everyday Law:
The Oath of Hippocrates, traditionally sworn to by newly licensed physicians, includes the promise that "Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret." The laws of Hippocrates further provide, "Those things which are sacred, are to be imparted only to sacred persons; and it is not lawful to impart them to the profane until they have been initiated into the mysteries of the science."
Doctor-patient confidentiality stems from the special relationship created when a prospective patient seeks the advice, care, and/or treatment of a physician. It is based upon the general principle that individuals seeking medical help or advice should not be hindered or inhibited by fear that their medical concerns or conditions will be disclosed to others. Patients entrust personal knowledge of themselves to their physicians, which creates an uneven relationship in that the vulnerability is one-sided. There is generally an expectation that physicians will hold that special knowledge in confidence and use it exclusively for the benefit of the patient.
Most psychiatrists I know (at least in Maryland) do not violate their patients' confidentiality unless 1) there is an issue of child abuse and this is because state law mandates it be reported, and 2) there is an imminent risk of danger to self or others. There may be reasons other physicians break confidentiality, for example the mandated reporting of contagious diseases or driving issues with epilepsy, but these do not generally happen in psychiatry. The thinking behind doctor-patient privilege is that no one would trust a physician if they worried their problems would be repeated. When I am not sure what to do, I will ask a trusted colleague, but there are clearly times when what is in a patient's best interest is not what's in society's best interest (such as prescribing an expensive medication or ordering an expensive test or revealing information learned in treatment) and I generally feel that my job is to keep my patient's best interest in front of me. It's hard to be everyone's agent.
For the most part, I don't endorse laws that mandate the reporting of past child abuse against the wishes of the patient (--not that anyone has ever asked me, but hey, it's my blog so you get my opinion) --at least not by psychiatrists as an after-the-fact event. In an Emergency Room with an injured child victim it's a different story and it's hard to imagine that it would ever be in the best interest of the patient to send them home to a violent setting. For psychiatry, I believe that such laws prevent people with problematic behaviors from getting help, and they prevent victims of abuse from having therapy if they do not want the scrutiny of the legal system or the turmoil that may bring if family members were involved. If a patient reports an active urge or plan to commit a violent crime, taking action is generally in that patient's best interest as well as society's and violating confidentiality may be the clear right choice.
In the vignette given in the Badly Behaved Behavior Health Care Practitioner, the situation asked whether a therapist should report a patient who is also a therapist who is having a sexual relationship with an adult patient. There is no "law" about reporting such behaviors (at least not in our state), though some Licensing Boards make statements that professionals are required to report colleagues who are impaired or incompetent. Some of our commenters wrote in to say that the therapist should be reported-- that patient safety should come first. My thought was that when a patient walks in the door for treatment, she is a patient and not a colleague and such licensing mandates do not pertain the way they would if the therapist in the next office knew illicit sexual activity was going on. It seems to me that the spirit of such mandates is to get the licensee help, something she is already doing by seeking care, and that these mandates were probably not made in the spirit of trumping confidentiality with patients, but I could be wrong. Reporting the therapist might help prevent future harm to patients, but in the big picture, it means that badly behaving psychotherapists can never get help in a confidential setting.
I suppose one way to get help for a misbehaving therapist to get help would be to seek care from a therapist in another specialty-- there is nothing in the Licensing Board mandates that suggests a licensee needs to report an incompetent member of another specialty or profession, so a social worker who is having an affair with a patient could perhaps seek treatment from a psychologist or a psychiatrist? And the other thing I wondered about-- does reporting the therapist necessarily help the current victimized patient? An adult patient, after all, is free to report her abusive therapist. If she chooses not to, perhaps there is a reason-- perhaps it would blow apart her marriage, or perhaps the inquiry that comes with such events would leave the victim feeling even more victimized. These aren't easy scenarios-- one can imagine all types of configurations-- the victim could deny the abuse/affair happened, the victim could be thrilled to hear that a confession occurred which will help with the prosecution, or the victim could feel not at all like a victim, but like someone who chose to have a consensual relationship and does not want the attention of the therapist's disciplinary proceedings.
These are really difficult situations. I'm not sure what the rules are for psychologists or social workers, but for physicians the default requirement is for confidentiality and there needs to be a really good reason to violate it, and revealing a patient's secrets may leave the psychiatrist open to his own scrutiny, disciplinary action, and lawsuits. We treat people even when they have behaviors or beliefs that are deplorable to us. I hesitated, however, to write this, because I can think of scenarios where confidentiality in the doctor-patient relationship might warrant a breech, and I'm happy I've never been faced with one of these situations.
Thursday, November 24, 2011
Tuesday, November 22, 2011
Monday, November 21, 2011
We've talked a lot about diagnoses here on Shrink Rap. We've talked about how diagnoses are made, how valid they might be, how as labels they can be stigmatizing or damning in a person's life. We've talked about how they are used to guide treatment and how they are demanded to obtain reimbursement for care. What we haven't talked about is how they hang out over time.
When I see a patient for the first time, we meet for 2 hours, I take a full history, family members may come in, and subsequent to the appointment, I may talk with a past psychiatrist, a current primary care doc, and I may request old records that I will review. I take the information I have and I form a diagnosis. Is it the right diagnosis? Oh, who knows. I don't sit there with the DSM and read off a check list and some of it is art. The DSM diagnoses aren't science, they were voted on by a committee. I come close. Like what is the exact divide between Major Depression, recurrent, mild versus Major Depression, recurrent, moderate ? To the extent that it guides treatment, I care about getting it right, but sometimes the honest answer is I Don't Know. Or the patient comes to me after they have gotten well--- they are not currently having symptoms, but they are on medications which they say help, and they report that before they were on medications, they had symptoms consistent with Diagnosis X. If they are medications that are usually used to treat Diagnosis X, if they had symptoms consistent with Diagnosis X, I believe them and diagnosis X.
So here's how treatment goes. Usually the patient has symptoms and the majority of the time the symptoms are consistent with a specific diagnosis and everyone agrees. Let's say the diagnosis is recurrent major depression, moderate in intensity, coded 296.32. I start the patient on medications for this condition and they come for therapy. A few weeks go by, and the patients symptoms get better, but they still have issues going on in their life. Stressful things that they are dealing with, or troubling relationships, or life just not going the way they'd like, so they still come for therapy. And each visit, a bill is generated and the bill needs a diagnosis, so the diagnosis remains, because this is what is being treated and this is what the patient is getting medications for, and so it's 296.32, even if the patient's symptoms are at bay, or even if the patient comes in saying that they are anxious today, or even if the patient spends the entire session talking about the fight they had with their sister and never mentions a word about their mood or symptom complex. The diagnosis is usually a stable thing for the paperwork issues that call for it. I mentioned statements for insurers, but in clinics, it needs to be on treatment plans, and in EMRs, and any form that goes to an agency which has regulations, including Day Programs, Psychosocial Rehab programs, Care provider organizations, etc. No diagnosis, no services. And some services are only accessible to the patient with specific diagnoses that indicate a severe and persistent psychiatric illness. I would say that for a patient who has had numerous psychiatric hospitalizations, is unable to work, gets benefits from the government because they are disabled by mental illness, and requires medication to remain well, it seems reasonable to agree that a major psychiatric disorder exists, even if on a given day, the patient says he is not having any symptoms of the illness and is feeling well. It has to be this way, or no therapy would ever be done: every session would be a diagnostic evaluation with check lists of symptoms. Now I'm not saying that diagnoses never change...they do...people get manic and we realize that their unipolar depression is really bipolar depression, or with time we realize that there is more than one diagnosis, or that a preliminary diagnosis was simply wrong, or that alcohol or drugs were a bigger contributor to the symptom complex than we realized at first.
But when our theoretical patient, the one with major depression, moderate, who had a long hard course with it, notes that a long time has gone by with no symptoms of the illness (on medications and with therapy) and he asks, "So do I still have depression?" it does make for an interesting session.
What do you think?
Thursday, November 17, 2011
In the first case, a psychiatrist is treating a nurse who is behaving badly. The nurse is stealing controlled substances from the hospital and giving them to friends who 'need' them. She doesn't intend to stop, and her contact with the psychiatrist was only for an appointment or two before she ended treatment. Should the psychiatrist contact the state's nursing board? Is he even allowed to?
In the second case, a psychotherapist sees a patient who is also a psychotherapist (I will call the patient here the patient/therapist). The patient tells the therapist he having a sexual relationship with one of his own patients (the patient/victim). This is clearly unethical, but the patient/victim is an adult and the relationship is "consensual" in that it is not forced or violent. There is no question that if a licensing board knew of this, the patient/therapist would lose his license. Should the treating therapist report his patient for unethical behavior? Ah, he asked a colleague on the Board and was told that he must report this, and if he doesn't, his own license could now be at risk. If he now reports it, as instructed, can the patient/therapist turn around and sue him for breaching his confidentiality? After all, he was seeking help with his problem, he believed it was protected information, and now he will be sanctioned out of a livelihood. Does it matter if the therapist is a physician (for example, a psychiatrist) as opposed to a psychologist or social worker or nurse practitioner? I realize that all mental health professionals have confidentiality standards, but are the confidentiality laws that apply to physicians/clergy/attorneys the same as they are for other mental health professionals?
Wednesday, November 16, 2011
Technology seems to be the theme of the moment here on Shrink Rap. We're all playing with new toys and trying to figure out what makes them fun and what makes them useful to our work.
For this week's post on Shrink Rap News over on the Clinical Psychiatry News website, I have an article up on Siri and the Psychiatrist. Some information that might be useful to anyone who is thinking of incorporating this technology into their practice, and oh, a little tongue-in-cheek humor there with many thanks to Dr. Bob Roca at Sheppard Pratt and Dr. Paul Nestadt at Johns Hopkins who both allowed me to quote them during their more playful moments. There is also a techy post up on Shrink Rap Today over on our Psychology Today Website with links to some of our past technology posts.
Roy is trying to figure out how to use his iPad to interface with Electronic Medical Records and wrote about it last week for our Clinical Psychiatry News SR blog, see iPad: The New Black Bag. His last post on Shrink Rap was about Depression Apps, and he inspired me to add the Moody Me app to my own iPhone. I haven't tried it yet, but I'll let you know how it goes, but the colorful smiley faces were more than I could resist. Depression Apps will also be a topic in one of our upcoming podcasts.
If you comment on it, it will make me really happy:
But be nice, I don't want to be sad:
Tuesday, November 15, 2011
In My Three Shrinks Podcast #63 (recorded last Sunday, to be out as soon as Clinkshrink completes it), we talked about reviewed iTunes apps helpful for screening for or tracking depression. I will provide a bit more focus on this topic here.
I recently wrote an article for Clinical Psychiatry News referring to the iPad as the new physician's "black bag." One of those tools might be a depression tracking app, to be used by patients or by providers responsible for treating patients. So, I went to the App Store (sorry Android users, I don't have one of those gizmos yet) and searched for the keyword "depression" and narrowed it down by filtering for apps which met the following criteria: Medical category; a rating of at least 3 stars; and at least 100 ratings.
- 9600 ratings
- not a rating tool but a nice 3D map of the brain
- interactive features
- 800 ratings
- uses a Zung depression rating scale
- 700 ratings
- uses a 27-item validated screen for depression, bipolar, PTSD, and anxiety
- displays graph of scores over time
- ability to send to your doctor
- also has a physician dashboard for reviewing trend of scores for all your patients
- 600 ratings
- an emoticon-based mood diary
- displays a graph of your scores over time
Health through Breathing: Pranayama
If you have used any of these, please tell us about your experience. If you have others you like, let us know.
*Disclosure: I have consulted for and collaborate with M3, the makers of DepressionCheck.
Sunday, November 13, 2011
The news media has published numerous pieces exploring various aspects of what happened at . The sports culture, the prestige of the program, the money it brought into the university, the parallels with the Catholic Church, and so on. What kept action from being taken by administrators after an employee allegedly witnessed a violent crime? What kept that employee from stopping a violent act? What kept him from taking further action later?
The media has looked at various aspects of these questions, but two aspects have received little attention: Is there a difference between the way men and women react to these events, and are there factors that actually inhibit men from taking action in these circumstances?
Here is a "thought experiment:" What would happen if the alleged crime were different-- if, for example, a man had walked in on someone violently raping a ten year old female child? Would he have reacted the same, observing but not interfering, reporting it up the line, but not taking subsequent action? What would have happened if one of the administrators who learned of this had been a woman? My thesis is that it would have been very different if it had been a little girl, and that women involved as administrators would have been far less likely to ascribe this to "horse play," look the other way, and remain passive after reporting it up the line to superiors.
A man coming across a heterosexual rape, whether of an adult or a child, would know immediately that this is a terrible crime and would have immediately stopped it. It would be clear that the police should be involved. I wonder whether the homosexual act, even with a child, arouses feelings in men that actually inhibit action, that make it easier to turn away and rationalize not taking action. It is something that is harder to confront, to even think about. To the psyche it is perhaps the most forbidden of crimes, worse than incest.
Again, the purpose of this post is to discuss the general principles, not the individual actions at Penn State, of this subject. What are the Psychological Factors that inhibit Action when Evil is