Monday, June 09, 2014

Is it Ok to Shrink your Sister in an Emergency?

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

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

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

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

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

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

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

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

61 comments:

Liz said...

i'm liz. i'm a (former) sort of social worker (resource coordinator), a (former) consumer of psychiatric services, and a current ministry student. in my family of origin, the rule was to help family out, no matter what. so if one of us was a doctor, the other should do whatever is most beneficial to help the family member in need; in this case, that means we would likely provide a prescription. if there is concern about suicidal behaviors, we might prescribe a very small number of pills at a time, though. that said, i have very real concerns about the safety and efficacy of those meds anyway, and would probably try to encourage my sister to find other avenues of coping in a healthful way. moving is stressful and i'm not sure that medications will be truly helpful...... at my home church, a friend was doctor and she sometimes called in prescriptions to help people out if she could tell what they needed, an antibiotic for some sort of bacterial infection, for instance, or an inhaler for a wheezy friend who has had one before but can't make it in to the doctor the next day. i don't think she would extend that courtesy or assistance to psychiatric issues though... more liability perhaps? more outside her range of expertise? my cousin is a (family) doctor, and he is a wonderfully kind man, but i don't think he'd prescribe ANYTHING to someone not a patient. i don't think he'd refill his mother's synthroid for three days until she could get her levels checked :-).... hopefully some true medical friends chime in :-).

PsychPractice said...

Tough One.
I actually had a similar situation with my niece, who was in college in my home town. She was horribly depressed and anxious, and I could see that she at least needed a trial of an SSRI. She was going home for the summer, and had arranged follow-up, but it was going to be a couple weeks before she met with the shrink. I had samples of Lexapro-I wouldn't have even had to prescribe anything-and it was excruciating, but I didn't give them to her. She never asked me for a prescription, and she didn't know about the samples, so she didn't feel bad about that, but I did. I just told her what I thought would be helpful, and encouraged her to discuss it with the new shrink. I did make myself very available to her, night and day, but that's about it.

The difference between the situation with my niece and your hypothetical situation is that my niece had never taken an SSRI. Lucy has been on zoloft, with good effect, in the past, so there's some sense of how she would respond. So if she's already restarted it with the meds from the walk-in place, then it's just a question of making sure she doesn't run out. I think what I would do is encourage her to return to the walk-in to get enough meds to cover her until she got to see her new shrink. If she wasn't able to get the interim meds from the walk-in, I would prescribe the zoloft, and tell her to cut the ativan to make it last. I'm more dubious about prescribing controlled substances for non-patients. And if the new shrink wasn't helpful, I would probably tide her over with zoloft until she found someone who was. And I'd insist that she call me every day to check in.
For me the question is, who is making the decision? If I had a UTI, I would write myself for 3 days of bactrim, because if I went to see my doctor, he'd treat empirically with 3 days of bactrim. So there's no decision there.
If my husband was running out of his antihypertensive and his doc was out of town, I'd cover him, because I'm not the one who put him on his meds. The fact that psychiatric illnesses are harder to diagnose than hypertension makes things more complicated. But I think I would feel like Lucy's old shrink made the original decision, and I'm just the facilitator.
All that said, my understanding is that the reason you're not supposed to prescribe for friends, family, or self, is that writing a prescription constitutes the establishment of a physician-patient relationship, and you can't have that with friends, family, or self.
Nice graphic, by the way.

Anonymous said...

Interesting thought exercise.

I would like to take it a step further, particularly the thought of those wise older psychiatrists who "talk about prescribing Valium for themselves".

You are in the process of writing a book on forced treatment. So why don't you prescribe yourself a 6 month regime of Zyprexa or Risperdal so when you talk about "forced treatment" you know first hand the effects of the drugs people are forced into? In most cases, "forced treatment" refers to mandatory neuroleptics.

It is very difficult to convey the humiliation of being restrained and being forced to do something you don't want to do willingly.

It is not that difficult that you yourself give a try to the drugs that the victims of involuntary treatment are likely going to be prescribed.

Dr Moffic said in the Psychiatric Times that he once tried Thorazine to see how that made his patients feel. He concluded "Not a pleasant experience, I must tell you".

With such exercise you can kill two birds with one stone: research for your book and the exercise you are presenting here!

Steven Reidbord MD said...

Hi, and thanks for asking. Yes, tough one. Here's how I think about it.

As a general rule, it's unwise to treat relatives or anyone else with whom one has a dual relationship. It's too easy to omit essential parts of the doctor-patient relationship — the sexual or substance-abuse history, not to mention careful medical documentation — too hard to maintain boundaries, too hard to be objective, etc. But rules are made to be broken in tough cases, and you created one with this (very believable) hypothetical.

Your headline tips your hand. "In an emergency" many things are ok that wouldn't be otherwise. While it's clearly not optimal for Brother Shrink to prescribe for his sister, under these far-from-optimal circumstances it's preferable to untreated suffering or urgent-care roulette, especially since Lucy had past successful treatment with Zoloft. If I were Brother Shrink I'd prescribe a therapeutic dose of Zoloft and probably a benzo if my sister were actively symptomatic and unable to get care for 3 weeks. Without active symptoms I wouldn't, because I wouldn't consider it an emergency.

Bottom line: when all your options are bad, pick the least bad option. And then don't use that reasoning when there are better options.

CancerDoc said...

I live in a rural community that is far understaffed w.r.t. mental health services. She will more likely be able to get an appointment with a primary care urgently who might be persuaded to prescribe said medications. Treating relatives, especially at a distance, is laced with potential pitfalls.

catnip said...

I am a user of SSRI's, but not a doc or in a medical related field. What I do is work with users of the employment insurance system. I have people coming to me and at times, begging for money, one of the factors is what efforts have they put into helping themselves? The sister is doing all she can to get help on her own and further efforts may cause more stress and harm then benefit.


The thing that got me about this case is that the sister has tried multiple other routes to get help without a solution and it isn't like there is a clear end point. She has seen 2 doctors without getting what she needs and it is a short term wait till she gets a into see her mental health provider in less than 3 weeks. While I understand that this is a slippery dangerous slope for a doctor, if the ground rules were clear, (I.E. I will only prescribe you enough to get you to your app't and we talk by Skype every other day) is this not a manageable situation?

In the past I had been on an SSRI and decided to go off it, after been miserable for 8 months I decided to go back on but my family doctor was on an extended leave and I didn't have a good relationship with her replacement. A specialist that I had since for awhile prescribed the SSRI (not his field) and did some monitoring with the agreement that it was only until my family doctor was back. It was a solution that worked for both of us.

In the end if it was my sister I would help her and if it was me I would hope that my sister would help me.

Anonymous said...

PA for 35 years.

Call psychiatrist and ask for call back clearly using all professional titles to ensure compliance. Get new psychiatrist on phone. Use all validators (where went to school and residency and offer office address) explain problem and request three week supply of Zoloft and ativan for sister or ask for sooner appt if new shrink uncomfortable.

If this does not work, plan B, prescribe drugs but write a memo to own files and register patient as such, identifying emergency and documenting all attempts.

Joel Hassman, MD said...

Not a black or white answer, and you know that. But, the real question isn't what brother should do now, but what he should do later WHEN sister calls/shows up at his door and asks for another prescription if he gave her one at the end of your vignette.

Once controlled substances are involved, the risk for further demands go up what, 50% at least?

Road to hell, what's it paved with?! Or is it fool you once, shame on whom?!

Anonymous said...

Lucy could not get an appointment with a PCP before the Zoloft ran out? She had 10 days. I bet she could get an appointment, and most PCP's would refill Zoloft. It doesn't sound like the only options are: the psychiatrist family member fills the drug or she goes without.

P-K

jesse said...

OK, I'll take a stab at this. First, in the example given, there are other options the sister, Lucy, has. One is calling the doctor who saw her in the ER and tell him that she had been on Zoloft and would he please prescribe it for a month. She would at the same time make an appointment with one of the psychiatrists in town. She could also call the doctor who had originally prescribed it to her and ask that person to call in a one month prescription. Assuming her health is good and she knows any other meds she is on, her old psychiatrist might be quite willing to do this. Does she have a PCP? A gynecologist? Your example has several reasonable routes for Lucy to take.

But Second, the question is posed in such a way to imply no other reasonable option is available, the brother knows her history, so what should he do? Are there exceptions to the Do Not Prescribe For Your Family Rule.

So let's just talk about that. The Board has basic guidelines, but as I have seen over many years they are intelligently implemented. So (and I am just saying what I think is reasonable) if the brother and his sister tried to get the Zoloft from the ER doctor, called her old psychiatrist (who could even be asked if he would talk to the ER doc), and she was not able to see a local psychiatrist for several weeks, the brother could give the prescription (while writing a note explaining the situation, his efforts to talk with/find a local doctor, etc., and enough of a history to make clear he was thoughtfully prescribing the medication. This last part is important - what if his prescription ignored important medical considerations?). But all he is doing is covering for a med that has been sucessfully used, so he does not have to write a lot.

My basic point is that what is expected is intelligent and responsible action. Certainly if a doctor were out in the woods, and a family member had an emergency (fall, animal bite, chest pain, etc. etc. there would be no one to call and emergency action would be expected, not criticised (unless it was negligently done, as is obvious...).

Borderline said...

Not a healthcare worker. Just a patient here.

I would think Lucy would just make an appointment with a GP. She has an easily managed illness if she already knows she responds well to benzos and zoloft. Beta blockers would work well too if the doc was anti-benzo. No one needs a psychiatrist if they have an uncomplicated case of Panic Disorder. Now if she had Panic and uncontrolled schizophrenia I could see why a pdoc would need to be involved.

Dinah said...

Liz: thanks for the family insights! I imagine family rules influence these things.

PsychPractice:oy on the niece, you get it.

Anon: I'm not sure why the fact that I believe our society needs to take a critical look at forced care means I need to take 6 months of neuroleptics. You say that as though I'm forcing this on other people. And I do treat plenty of people who voluntarily want to take neuroleptics, function better and feel much better with them, some of whom I am encouraging to give a trial off. I'm reading a vindictive tone into your 'suggestion' which is enough to make some one who might be on your side want to wish you'd go away.

Steve: thank you for the practical wisdom.

Cancerdoc/Jesse/Borderline/P-K --is it easier to get an appt with a primary care doc when you don't already have one? This is hard, someone is in distress, needs to identify a new doc, get an appointment within days, hope they like the doc, hope the doc will prescribe what's been helpful. It may be easier, Lucy just didn't know and was running around to ER/Urgent care, looking for a psychiatrist, going to work, get the kids from carpool, and feeling very strung out, the Find a Primary Care Doc (her one call resulted in "next appointment in 8 weeks), was more than she could manage. New appointments with GYNs: ~3 months.

Joel: sister has a history of finding the meds to be helpful for the short term, no history of overuse, abuse, or drug seeking. She is happy to get her meds appropriately from a shrink, she just can't get an appointment soon enough. This is about prescribing when there theoretically are other docs (she's not in the hills of North Dakota), and she understands that Shrink Brother is anxious about this and she is not asking, he is wondering if he should offer. We have zero concern that this will be a regular plug at brother for drugs of abuse. Don't be such a cynic, everyone isn't a drug addict or trying to milk the system, some people are just suffering.

Jesse: really? Go to ER for a problem and then later CALL and ask to talk to the ER doc to request something. I can't get a specific ER doc to talk to me when my patient is in the ER. Then ask the ER doc to pull the chart and phone in more meds! Lucy tried this with the urgent care center ans was told she had to come back and maybe they would or would not prescribe more meds. She could have tried, but she didn't have childcare, The wait in the ER had been 10 hours with the whole r/o MI thing and the place was a zoo, so she felt guilty going in for something as extraneous as "I want zoloft.
She could have tried harder to return, to get a family doc, to find a psychiatrist to see her sooner (there was one who had an earlier opening but he'd recently gotten his license back after a yearlong suspension). Some sympathy for the idea that she's feeling emotionally fragile, has 3 kids that need care and the nanny is sick and a bunch of deadlines at her own job and the voicemail menus take hours and lead her to dead ends?

Jesse/Steve/PA

Dinah said...

And finally, I want to know why no one railed on me about why should Lucy be different then any other person who might be in the same situation but not have an MD relative or some special connection? People are routinely given clinic appointments in 4-6 weeks with no option aside from the ER for treatment.

It sucks.

Borderline said...

I don't know where Lucy lives or her insurance. But where I'm from, it isn't difficult to see a primary care doc. In fact, I'm seeing more urgent cares cropping up that double as primary care offices so you can get a same day appointment. I see a doc now who doesn't double as an urgent care but can do same days. There are some really busy practices, but I've never heard of it taking eight weeks to get an appointment.


When I was on Kaiser, it could take a week and a half or so to get an appointment. But if you needed to see someone sooner, you could get a same day appointment with an NP or PA.

I think pdocs are always harder to see.

Steven Reidbord MD said...

A couple more thoughts. This post is a projective test of sorts. Do we accept that Lucy has no other reasonable options, or is she overlooking a shortcut? Oh look, there's a PCP with an opening she didn't notice before! The ER doc was so kind (and always on duty) that he or she will bail out Lucy, just this once. I assume Dinah wrote this to preclude deus ex machina solutions. The scenario also portrays Lucy and her brother as earnest, neither aiming to be sneaky, work the system, cut corners, etc.

As I read it, the question then boils down to situational ethics, i.e., our individual willingness to bend rules in particular cases. How important are slippery-slope arguments? How important are rules? My own view is "pretty important but not definitive." Your mileage may vary.

Dinah's last point is important, and I thought to include something on this, but I'm already too wordy. The only difference between Lucy and many, many other patients is her Brother Shrink. Yes, it sucks. And I see no ready solution, no deus ex machina, given the health care system we have.

Dinah said...

Since this keeps coming up: Lucy has made a reasonable effort to find a psychiatrist or obtain medications through the usual means, she's not trying to work the system.

But is she obligated to call every single primary care physician, GYN, and psychiatrist? Sit through their voicemail hell, be told that they aren't taking new patients, or she has the wrong insurance and can't be seen at that practice.

She's supposed to do this, to an unclear, leave-no-stone unturned attempt, for how many hours a day, and we'll cut no slack for the fact that her psychiatric disorder might leave her feeling fragile, less able to cope with the usual life non-sense, frayed, and having difficulty negotiating the care of her children and job.

What if the story was that Lucy heard of a wonderful psychiatrist who could not see her for 2 months, and she wanted that appointment, because another psychiatrist who could see her in 2 weeks only did 15 minute med checks, had a reputation for being obnoxious and insensitive, or had some issue that Lucy found very troubling (she's black and he's a known member of the KKK in their town).

I don't know if it's okay for Brother Shrink to prescribe,
but once the distressed patient has made a few efforts to address this (and the bill for her ER visit came in at $900 btw, deemed non-emergent by insurance, and EKG and enzymes/labs to r/o heart attack. Insurance said not warrented because of her young age, no chest pain, h/o of panic disorder).

Have some mercy people and stop blaming the patient for not jumping high enough through the ever moving hoops

jesse said...

If anyone would like to immerse himself into an area of regulatory rules and their implementation, the link below is illuminative. Robert Kagan was director of the Berkeley Center for the Study of Society and the Law. Listen to his interview and the following questions (it is long, but worth it)

In terms of the example here, the point is the argument that the rules preclude the psychiatrist prescribing even Zoloft to his sister under the circumstances, and then the question is whether, in fact, he could prescribe.

The fact is that the Board in Maryland would not have a problem with this circumstances if it were short term and if reasonable efforts were made to find another doctor and some documentation existed.

But listen to what Robert Kagan has to say:

http://www.law.berkeley.edu/9603.htm

Borderline said...

But Dinah...is it really that hard with insurance? Don't you just call the company and they refer you to a PCP? If it's HMO then you automatically get assigned and the doc is on your insurance card.

It doesn't take hours and hours to find a primary care physician and jump through tons of hoops when you have insurance. They give you at least three names of docs over the phone. They can call and make an appointment for you in some cases. Unless she lives deep in the Ozarks and she gets seen at some health mobile that travels through the mountains treating folks too far away from civilization to be seen at a regular office.

I get a poor person being in this situation because they have no money and rely on community mental health, but I don't know how someone who has a private nanny (who can afford that in this economy?) and health insurance would have a problem like this. I've never heard of "rich" people (and when I say rich I just mean much richer than myself) not having access to care. Cut out the nanny and go concierge if she wants quick help.

Borderline said...

Sorry if I'm too snarky. I read this and something gets under my skin. I think, Ugh! Rich people problems.

joel Hassman, MD said...

Have you worked in Community Mental Health with any regularity for the past 5 years? I am at a clinic now where SEVENTY PLUS PERCENT are on controlled substances, so call me a cynic, I prefer to be a hardened realist.

And, I said a 50% likelihood of the family member coming back, not 90%. But, keep on underestimating what happens when benzos are introduced quickly and with such compassion to those who are looking for instantaneous relief. It reinforces those adages I ended my last comment with.

Man, it must be nice to practice in isolation and comfort, sorry I don't have all these cushy jobs most who blog and comment here give the impression!

But, thank you for at least acknowledging the prior comment.

Anonymous said...

Dinah, my experience is that it is very easy to get in with a PCP, but then I live in a large city. I didn't have a PCP, and I needed to see someone promptly so I made an appointment online through ZocDoc. The internist who had never seen me before offered to refill Latuda (even though I didn't ask and didn't need him to). The physician is going to be so relieved the patient is not there asking for a benzo or other controlled substance, they will be more than happy to refill Zoloft.

Maybe more of an issue getting an appointment with a PCP if she lives in a rural area but not a problem in a city, from my experience.

P-K

Anonymous said...

Psychiatrist:

A common problem. I responded on the blog, but here it is again: the brother should prescribe the proper dose of Zoloft. She's very unlikely to get manic or suicidal on it, and it is only three weeks, it's hardly necessary to have an unpleasant conversation about sexual side effects. As for the benzodiazepines, she should split the existing pills in half, use them wisely, and do her breathing exercises. Nobody who is not in status epilepticus "needs" benzodiazepines so badly that it's worth jeopardizing her brothers medical license. Lastly, the brother should create a rudimentary chart for his sister, listing things like allergies and concurrent medications and a basic history, and then stick it in the desk drawer in case he is ever asked to produce it.

Dinah said...

So I did my own experiment. Called my health ins company: 6 minutes. Got 2 names.
Called first name: office closed on Wednesdays, call back tomorrow (no message, no receptionist).
Called 2nd name-- part of massive group. Got receptionist Tracey's answering machine and left a message. Am told she will respond with 24 hours.
Tried another name from ins co. website: doc not taking new patients, 2 other docs in group, one could see me first or second week in July, but she would not say exactly which date (I asked twice).
Emailed two PCPs I know. Neither has responded.

So how long is our distressed patient supposed to plug away?

I'll let you know what happens.

Anonymous said...

Dinah,

You need to tell "Lucy" about ZocDoc. They're awesome. You can put in your insurance and search for practitioners by specialty. You make your own appointment online. No waiting on hold and no talking to a receptionist. Quick & easy. I found my dentist and internist through ZocDoc. They've both been great. (I don't work for ZocDoc, by the way, I've just been really pleased with their service).

P-K

Anonymous said...

I put in my zip code & insurance on ZocDoc for a primary care provider. I stopped counting at over thirty family practice or internists who had available appointments within 1 or 2 days. There were pages and pages more, I just stopped counting. Lucy isn't trying.

Borderline said...

@Dinah: I don't know for every insurance, but if you have mental health benefits they often have a mental health line and you can speak to a social worker. If you said you were having uncontrolled panic attacks and needed help ASAP they would help you out. They would probably even offer to call one or more psychiatrists to get you in quickly if they thought you really needed it.

You just have to emphasize that it is not a routine followup or some such thing. When I had trouble getting a pdoc to see me, the mental health line offered to locate, call, and schedule the appointment for me.

But I don't know the quality of every insurance. They would rather get you into a doc than have you go to the ER for a psychiatric emergency.

Anonymous said...

Anonymous Psychiatrist said "As for the benzodiazepines, she should split the existing pills in half, use them wisely, and do her breathing exercises. Nobody who is not in status epilepticus "needs" benzodiazepines so badly that it's worth jeopardizing her brothers medical license. "

And if she has been taking the ativan every day, cutting the existing dose by 50% could put Lucy in severe withdrawal which is quite dangerous. Brother should prescribe enough for her until she can see her doctor.

AA (not a medical professional but has hung out on withdrawal board where people have suffered severe adverse effects thanks to advice like this)

Anonymous said...

As far as finding a primary care physician, when I called one person, I wouldn't have been able to get in for about 4 weeks. But when I thought I was going to have surgery, I needed to see someone pretty quickly for a preop evaluation. Shockingly, was able to get an appointment within 2 days. I guess it just depends.

AA

Joel Hassman, MD said...

And, for readers to appreciate my point of view about benzos being minimized by colleagues, check out the article in USA TOday yesterday:

http://www.usatoday.com/story/news/nation/2014/06/10/senior-citizens-prescriptions-addiction/10088759/

Not a fun read, note the mention of xanax and ativan there.

raise your hands if you know someone who innocently was prescribed a benzo who became at least dependent on it, if not frankly became addicted to it?!

Anonymous said...

Dr. Hassman, I found your points about Benzos ironic. Recently, you were on the MIA site essentially accusing all of us of being extremist anti psych nuts who take an either or position. But yet, in my opinion, that is exactly what you are doing with benzos.

By the way, I do share your concern that they are way over prescribed and applaud you for that. But that doesn't mean everyone on a benzo, including me (take on a very limited prn basis for sleep) should be treated like we are guilty until proven innocent because we take a med that has a bad reputation. I think they call that treating people with respect.

AA

Anonymous said...

Clinical psychology student here.

My first thought was: Panic Disorder is actually one of the disorders better treated and controlled using CBT. You mentioned that the sister is having "therapy" without specifying type and components. "Breathing exercises" a.k.a. avoidance? Great. How about some interoceptive exposure?

I'd suggest she finds (or the brother helps her find) a therapist well-versed in evidence-based interventions for her type of problem.

I guess everything looks like a nail when you're a hammer - and this applies to both psychiatrists and psychologists.

Joel Hassman, MD said...

Give me a break, AA. First of all, I see the gray in things, and I do write for benzos in patients who are new to both me and treatment, but, tell me and the rest who are attentive and responsible how 60% of a community mental health practice are on benzos and over 2/3's of those on such meds are on dosages that exceed safe and reliable dosing for treatment, not just fueling dependency or addiction? Such prescribing done by my predecessor or other lame physicians who overprescribe and then dump it on another to take the responsibility.

Frankly, I feel your comment is at least a bit projecting your polarized view onto me. And, MIA is just Furious Seasons Redux or Junior.

Wow, forget that post and thread there I stupidly commented at, the general theme of that site is lynch and maim anyone with an MD and psychiatrist in the same sentence.

And, I think you honestly know that. Can we just dump the dishonest and disingenuous rhetoric once in a while to show some frank candor and core belief, please?

At least you do say it with some respect and diplomacy, I will give you that.

Oh, and having patients with alleged ADD on high dose stimulants AND high dose benzos simultaneously, gotta love that!

And now, I end this sidebar at this thread. But, the fact that the vignette did mention the use of a benzo did legitimately raise the issue to some degree.

Thank you again to the blog authors here for the opportunity to comment, that is said sincerely.

Joel Hassman, MD said...

Give me a break, AA. First of all, I see the gray in things, and I do write for benzos in patients who are new to both me and treatment, but, tell me and the rest who are attentive and responsible how 60% of a community mental health practice are on benzos and over 2/3's of those on such meds are on dosages that exceed safe and reliable dosing for treatment, not just fueling dependency or addiction? Such prescribing done by my predecessor or other lame physicians who overprescribe and then dump it on another to take the responsibility.

Frankly, I feel your comment is at least a bit projecting your polarized view onto me. And, MIA is just Furious Seasons Redux or Junior.

Wow, forget that post and thread there I stupidly commented at, the general theme of that site is lynch and maim anyone with an MD and psychiatrist in the same sentence.

And, I think you honestly know that. Can we just dump the dishonest and disingenuous rhetoric once in a while to show some frank candor and core belief, please?

At least you do say it with some respect and diplomacy, I will give you that.

Oh, and having patients with alleged ADD on high dose stimulants AND high dose benzos simultaneously, gotta love that!

And now, I end this sidebar at this thread. But, the fact that the vignette did mention the use of a benzo did legitimately raise the issue to some degree.

Thank you again to the blog authors here for the opportunity to comment, that is said sincerely.

Anonymous said...

Joel,

What a lack of empathy :).

You are misrepresenting the MIA readership. Most people there do not have anything against shrinks in general (although some do think that somebody who voluntarily chooses to become a shrink was born with a moral failing of sorts); the shrinks that have been virtually lynched are those who unashamedly defend forced so called "treatment" or that "poisonous psychotropic drugs are good for you".

It's like having some white guy going to a segregated city of the South in the 1950s and saying out loud "Jim Crow laws are good for you, look at all those schools that were build with people like you in mind!". Said white guy should expect to be welcome with open arms.

A similar analogy is a rapist going to a convention of rape victims giving a talk about the benefits of forced sex.

When MIA started 2 years ago, the most prominent representatives of the psychiatric quackery were Moffic and Sandra Steingard. Moffic never understood that preaching pain to those who had suffered at the hands of his quackery was unwise. Sandra Steingard understood pretty well what was going on and her more empathic abilities has made her somebody that most MIA readers respect, including those who disagree with some of her positions.

I am not sure what thread AA is talking about, but from my previous interactions with you in the boring old man website and your own, you sound pretty "Moffic" to me, so you shouldn't expect a warm welcome from victims of psychiatric abuse.

Anonymous said...

Patient--just chiming in because I cannot believe there are so many people who think you can always get a new patient appointment with a PCP so quickly. I have decent insurance but recently when faced with finding a new PCP I had to sift through a list of doctors, make calls only to be told that even though the insurance company provided their name they're not actually accepting new patients, and when I did FINALLY find a PCP on my insurance who was accepting new patients it was a THREE MONTH wait for the appointment. I'm sure I could have kept making phone calls and found someone with a slightly shorter waiting time, but the process was so stressful and frustrating that there was only so much of it I could handle. I ultimately took the 3 month appointment and used an urgent care center for my needs until I could get re-established with a PCP. And no, I do not live in a rural community...a fairly large city actually.

Anonymous said...

Last anonymous before me, to be honest, I was pretty shocked I was about to get an appointment so quickly with a PCP when I thought I needed a preop evaluation. And it wasn't a fluke because when I needed a followup, I got in very quickly. I feel very lucky because I really like this doctor and plan to keep her as my PCP.

I don't know if that is an aberration or not as I live in a large metropolitan area. I suspect I was very lucky based on previous experiences in getting an appointment with a new doctor.

Anonymous who wrote response to Dr. Hassman, thank you so much for what you said. You nailed it precisely.

Dr. Hassman posted on the Philip Hickey blog entry about psychiatry and chemical imbalances. Anyone who goes to that thread can make up their own mind as to what happened. In my opinion, people were quite respectful to him and asked some good questions that he conveniently never addressed.

AA

Joel Hassman, MD said...

Yeah, I am so out of line in challenging the antipsychiatry folks who "peruse" these blog sites.

This is something Dr Hickey wrote earlier this year, really dispels my opinion if he is a regular writer at MIA:

"Psychiatry has damaged and killed human beings who came to them for help. They have routinely disempowered people,
and have spuriously equated all human distress to their confidently-touted, but fictitious, chemical imbalances, and, more
recently to the twitching of aberrant neural circuits. They have arrogantly promoted themselves as the arbiters of
normalcy and the healers of emotional pain. They have systematically undermined the notion of self-improvement
through effort, and through natural social support networks. They have enslaved millions to their toxic psychotropic
chemicals. And we haven’t hit bottom yet."

from this site:

http://survivingantidepressants.org/index.php?/topic/5962-benzodiazepines-dangerous-drugs/

Wouldn't it have been more responsible and respectful to say "Too many in psychiatry...". But, no, damn away everyone, guilty for simply being in the profession.

As AA notes above, if other readers are interested, read that post by Dr Hickey and the thread, and not just my mistaken efforts to add, but the WHOLE thing.

http://www.madinamerica.com/2014/06/psychiatry-promote-chemical-imbalance-theory/

Just to clarify from Dinah, was the intention of this post to illicit colleague feedback primarily, or just be completely open ended from any perspective?

It is like witnessing a car crash, depending on where you are at the intersection, who is at fault?

Anonymous said...

AA,

I just read the exchange in the Hickey thread. Priceless. Very Hassman like (or Moffic like since it is difficult to tell the difference between the two).

I found particularly offensive his "blame the victim" line of argument and his reference to psychiatrists as Jews prosecuted by Nazis when in fact,

a) Action T4 is there to remind everybody what German psychiatrists did during Nazi Germany

b) The legal power to lock up people that his guild finds distasteful via the bigotry manual known as DSM belongs to psychiatrists no to their victims. Joel, I trade places any time. There are a few psychiatrists that I would love to recommend for involuntary inpatient treatment :-).

BTW, this is cannotsay from MIA (also the anonymous above).

Anonymous said...

Just a patient. When my doc was not around, I had to go to an urgent care center, and they gave me a prescription to tide me over.I went back a few times until my doc became available. Since Lucy has directions from the hospital as well as directions regarding which meds to take until her appointment in three weeks, she can certainly haul herself back to the center and get refills to get her through to the time she sees the psychiatrist. There is no need for her brother to become involved. In fact, if you were dealing with an individual who did not have a shrink family member, that is exactly what they would do--go back to the urgent care center once or twice more. I am going to bet that if Lucy had an urgent gynecological problem and her brother was a gynecologist, she would choose to go to a clinic over having her brother examine/treat her. This is about poor boundaries and people who need to put up with a bit of inconvenience, but it does not sound like any kind of emergency that would necessitate a family member getting involved.

Borderline said...

I checked out Minute Clinic from CVS, and I didn't know they will give you a one time refill of up to 90 days on a prescription. I just thought I would post it as knowledge for people to have besides the zocdoc reccomendation.

http://www.minuteclinic.com/services/wellnessandprevention/medrenewal/

Anonymous said...

Can't Say, good to see you here.

Dr. Hassman, have been thinking alot about your last response. I am probably an idiot but I am going to try another way to respond to you in the hopes that I receive a respectful reply.

Regarding your feeling that people are unfair to psychiatry, let me ask you this. There is one writer on the MIA site, Dorothy Dundas, who underwent 40 insulin coma treatments which many people would equate to torture. Even if psychiatrists don't agree that it was, I think everyone, no matter what you currently think of psychiatry, is pretty horrified these treatments were used. In your opinion, should Ms. Dundas be required to take a moderate view of psychiatry in light of the horrific experiences she had?

I guess my point is if someone has had a horrific experience in any area, is it really fair to ask them to be moderate? Personally, I don't think it is but if you feel differently, I would love to hear why.

On a less serious note, you seem to despise politicians on both sides of the aisle. I will bet if I told you that you shouldn't stereotype all politicians as bad, you would be livid. But yet you want to do this to people who have had horrific experiences with psychiatry. Why?

And by the way, I know this may shock you but psychiatrists aren't the only group of people who are demonized.. On the apnea board I hang out at, it is the durable medical equipment companies who are the villains. They have more than earned that reputation in my opinion. But no one posts on the board criticizing people for being anti DME and needing to moderate their position. I don't understand why people who have had a horrific experience with psychiatry should be treated differently.

Regarding comments being off topic, actually, when I mentioned you posting on MIA, I was using that to make a point that related to this blog post. Unfortunately, that did result in off topic discussions but that happens. I do realize this post is off topic and I think the shrink rappers for their patience regarding this. But I did want to try one more time to respond to you which I realize may be very short sided on my part.

AA

Joel Hassman, MD said...

As I said earlier, you, AA, are the most respectful and willing to dialogue of those who are reflecting an outward harsh and pervasive disdain of psychiatry as a near whole, but, I "take on the antipsychiatry crowd" at other sites outside my own blog because of basically two reasons:

1. the extremist, polarized, and overgeneralized attitudes of such commenters that go on without challenge will be accepted by readers who do not see there are others who do not embrace the behaviors and attitudes the antipsychiatry critics HAVE SOME legitimacy to attack per specific providers, and
2. A lot of these other blogs just want the traffic, want the hits, want the dialogue to be seen as some popular and /or allegedly valuable site for information and authority. This specific opinion is not outwardly directed to Shrink Rap, but, there are past threads you have to wonder why there has been such pervasive silence or minimizing of harsh commentary by those who just viciously hate all psychiatrists.

Yes, blogs do what they want, but, I am not going to just sit in front of the screen reading such vile and venom saying everyone who is a psychiatrist should be exempt from the world. So, I write what I write, the authors can call me out or just delete it, but, it is similar to rhetoric by disgusting past examples of polarized and destructive entities like the political examples I noted at MIA.

Case in point here TODAY in American, the polarized views by Democrats and Republicans are the largest margin of difference seen in over 30 years. There is little to any interest in moderation or honest and fair debate by the public as a majority. Fits consistently with what I say repeatedly at my blog, yes, the politicians stink as they are elected and reelected for decades by a sizeable percentage of ignorant, selfish, and inconsiderate electorate. That is not directed to any one person here, but, tell me I am genuinely wrong in that appraisal when you look who leads the two parties today.

As per your example with Ms Dundas, I don't know her situation to comment with any authority, but if she was mistreated, abused, or just neglected by specific providers, she has every right to be offended and outraged with THEM, not me, nor anyone else who did not interact with her nor reflexively defend her mistreatment experiences.

Sorry, you might not accept this comment, but I am NOT the typical psychiatrist of 2014. I embrace my training and focus on individuality and a multifactorial treatment intervention process, but, as my current "incarceration" nears completion with the Locum job at now, I am forced to prescribe until proven otherwise if I want to be employed.

But, I don't do it without challenge or debate, and frankly, I meet people every day who don't want to problem solve, just stick with the status woe and don't give a rat's buttocks what happens at the end of the day, both patients and colleagues/administration.

Which is why I do Locum work now, stick with it for 2-3 months and then get the hell out. I'll be posting about this at my site later today, but, since you asked here I write it here first.

I think what readers and commenters should be asking both of other blogs and commenters who seem to defend the status woe of psychiatry today is simply this:

"As a provider/clinician, if you just take a stance that psychiatry is 'that's the way it is, some things will never change' or an alternative of 'I hear you and empathize but there is nothing I can do besides print your outrage and complaints, but I won't take on the negligent/uncaring authority that rules psychiatry', then what is your agenda in blogging?"

Let's be honest, if I don't write exactly what the antipsychiatry crowd wants as choir echos, I am a villain. I have been reading it for 4 plus years now. Isn't that how tyranny grows and thrives?

Anonymous said...

Can't Say here :).

AA,

Thanks for your very thoughtful comment. As expected, Joel's response is disappointing.

Joel,

There is a discussion going on at MIA in a blog by James Schroeder on what's the point of psychiatry/psychology. I am not going to repeat every argument here (interested readers can go there) but my understanding is that James Schroeder has basically conceded that "psychiatry/psychology" are professions attempting to do "mind control for the benefit of humanity". He justifies both with a utilitarian appeal to "natural law", in the same way theologians appeal to "the moral law", to justify why the APA version of what "behavioral orthodoxy" should be is THE RIGHT ONE.

While I am happy to have read what he said, the argument is self defeating. The first amendment of the US constitution, a breakthrough in the development of Western civilization, exists precisely so no holistic version of what "behavioral orthodoxy/morality should be" is adopted by the state. Individual issues (like homosexuality whose criminalization was declared unconstitutional in 2003) can only become law if adopted by the representatives of the people not because a group of "self appointed, unaccountable, mind guardians" push it top down through the force of government.

This sad state of affairs, that Thomas Szasz called "The Therapeutic State", is what we have today. Except for the issue of involuntary treatment, where our side won significant battles in the US during the 1970s, I see the Therapeutic State pushed forward by the mind guardians of the tow APAs stronger than ever. In 2008 GW Bush signed into law the "mental health parity act". Obamacare contains the APAs vision of "mental health" as one of the essential benefits all plans have to offer to Americans (who are by law mandated to have one). Measured by the expenditures in psychotropic drugs, the "Therapeutic State" has a size unimaginable by Thomas Szasz or R D Laing in the 1970s.

We won some important battles on the matter of involuntary treatment (at least for now), but everywhere else, I see psychiatry subjugating more innocent victims than ever.

This is why people like me will continue to denounce the psychiatric quackery. Not because it is a quackery -I have no problem with people who believe in quackeries and fund them with their own money-, but because of its undue and unconstitutional influence in the lives of innocent Americans.

Borderline said...

It's almost like a formula now. Dinah posts blog entry. People quickly hone into off topic matters. Joel makes an inflammatory comment. Multiple readers respond to Joel. The thread becomes entirely about Joel and readers' reactions to him. It's mind boggling.

Anonymous said...

Borderline,

This is how Joel operates in all his interventions, either here, the old boring man, his own website and recently in Mad In America.

In all cases too, he likes to portray himself and psychiatrists in general as victim(s).

And yet, I am happy that he does what he does. Nothing makes the case stronger against the psychiatric quackery than a "victim complex" megalomaniac shrink.

You can always tell friends who have doubts about whether they would benefit from a contact with psychiatry: gee, see for yourself what you are getting yourself into. Your shrink might be somebody like Joel (or Moffic).

Joel, please continue with your tactics. You are doing a fantastic job!

Anonymous said...

Why not spend a few minutes with your sister... "What's going on in your life?"

Just askin'

Anonymous

Joel Hassman, MD said...

You really have to both laugh and be astonished with how hypocritical and projective people are in their attacks not just on me, but anyone who speaks even remotely positively about psychiatry.

Yes, I have a tactic, which I clearly stated above, calling psychiatry a monstrosity of the world is no different than the Nazis calling the Jews the evil of the world.

But, I leave readers with this thought, which will inflame the usual suspects, but perhaps give some pause and reflection to those who genuinely and respectfully want the debate to not only continue but have resolution so care is maximized and protection of rights is respected:

What is going on with getting Gay rights respected in society with the extremists who are out to destroy anyone who dares to speak against "the cause", is there really no difference with the extremists here that define outwardly the antipsychiatry movement?

Yeah, making people lose their jobs and be ostracized is really going to gain respect and admiration from the general public.

For every "Victory" extremists allegedly gain by harassing and vilifying people who are holding true to core beliefs but also do respect the public around them, the "Defeats" will be coming.

You antipsychiatry zealots need to remember the adage of "see the forest for the trees".

Oh, and I did reference the more recent post at my blog noted above by anonymous/Can't say here per Schroeder. Hey, the thread does not dissuade any attentive and responsible reader from my interpretation of how MadInAmerica operates.

And to end this last comment by returning to the point of medicating a family member, again, it is NOT a black or white issue overall, but, my point I first made was be careful at least in writing for controlled substances, that is a loser much more often than a winner. Yeah, it is nice Dinah sets up the vignette to know how it will play out in her case, but, I still know from my experiences out there from the alleged "compassionate and concerned" physicians and family members that "the road to hell is paved with good intentions".

Maybe the better future vignette from the authors here should be "what do you do when you are asked to see a patient who a family member as well as a colleague started treatment first and has possibly created complications while intending to be helpful"?

Been there, had it done to me.

See ya at another blog or future post here, psychiatry haters. You are more than welcome to bring it on at my site.

Oh, moderation does take away from instant gratification, but know this, I have only deleted two comments in my history there, one for just repeating the same thing in different words, which the commenter agreed in follow up, and the other who was incoherent in commentary, and I did acknowledge the effort by the writer, who did not come back to clarify.

Cheers.

Philip Hickey said...

This is in response to the first comment left by Dr. Hassman on June 13.

Dr. Hassman is making a fair point.  Obviously there are some psychiatrists who practice in accordance with different concepts and procedures. I frequently note that fact in my writings, but did not do so on this occasion.  Sometimes I use the term "organized psychiatry" or "mainstream psychiatry" instead of just "psychiatry."

On the other side of the coin, however, it needs to be acknowledged that there are extremely few psychiatrists who challenge or operate outside of the standard model.  And secondly, very few psychiatrists speak out against the standard model.

Finally, there is, in my view, a measure of reasonableness in conceptualizing psychiatry as a unified entity.  The vast majority of psychiatrists subscribe to the position that all significant problems of thinking, feeling, and/or behaving are medical illnesses, and they look to the DSM for guidance as to what these "illnesses" are and how they should be diagnosed.

In addition, psychiatrists have organized themselves at state and local levels, and more recently at the international level (World Psychiatric Association.  But I have never been aware of a single psychiatric association (other than the British splinter group Critical Psychiatry Network) that has spoken out against the standard model.

The passage of my writing quoted by Dr. Hassman is extremely critical of psychiatry.  By objecting only to my failure to note the few exceptions, Dr. Hassman is implicitly endorsing these criticisms – or so it seems to me.  He faults me for tarring all psychiatrists with the one brush, but if my criticisms are valid, aren't there only two courses of action open to an ethical person who belongs to this group:  either exit the profession, or distance oneself literally and conceptually from the spurious and disempowering practices.

Anonymous said...

Can't Say here :).

Phil,

Great to see you here! I believe you are being too kind with Joel. Remember the discussion with Bernard Carroll, in which he bailed out when he couldn't coherently defend his psychiatric nonsense? Joel is like him, except he is less polite, you'll see.

Joel,

So much garbage in what you say that it would take a lot time to address each point with a decent amount of discussion.

Let's start with the continuous appeal to seeing yourself and other psychiatrists as Jews prosecuted by Nazis. Not sure if this is a psychiatric joke, but checking the civil commitment laws at the state level (both patient and inpatient) or the Murphy bill, I see that the DSM is referred to explicitly as the gold standard to delineate who is human from who is subhuman (to whom standard civil rights protections against coercive treatment and incarceration without the commission of a crime do not apply). I haven't seen in any of those laws references to manuals written by survivors of psychiatric abuse saying that it is psychiatrists who should have their civil liberties restricted.

Perhaps you are suffering form delusions that would qualify you for a diagnosis of schizophrenia or bipolar disorder???

Then, it is funny that your last post confirms Borderline's analysis how you make every single thread about yourself after making some inflammatory comment. So here we are again, you making an inflammatory comment...

With respect to homosexuality. I agree that people should be free to express their views without fear of retribution, but that is not what psychiatry does. Psychiatry does not "express views". It maligns millions of Americans with invented diseases and then it lobbies for having the people who exhibit the patterns of behavior psychiatrists dislike lose civil rights through the coercion of government.

That is very different from the campaigns against the Duck Dynasty or Brendan Eich. In each case you had free speech protected by the first amendment. In the first case , A&E did the right thing, in the second case the board of Mozilla cowardly bowed to pressure. In NEITHER case, the pro gay marriage zealots used the coercion of government in their campaigns, as organized psychiatry does.

Again, you seem deluded to me. If I were you, I would check with one of your psychiatric peers to see whether you can be officially diagnosed with bipolar disorder or schizophrenia.

Finally, you say, "you are more than welcome to bring it on at my site", you forgot to add "only if you agree with my views". I have posted there before and I was moderated and insulted, which is why I know that you are the kind of "victim complex" megalomaniac psychiatrist that gives your profession the bad reputation it deserves.

Cledwyn said...

This is to Mr Hassman.

The comparison relating generalizations about Jewish people in Nazi Germany to attitudes about psychiatrists, only hammers home the point that being a psychiatrist is no insurance against irrationality, and his further comments on here also go to show that it is not just the patient who often has trouble containing his emotions within judicious limits.

Firstly, you are comparing apples and oranges.

The term "state psychiatrist" denotes an occupational identity, not ethnic or religious identity.

For this reason, it would be more accurate to compare state psychiatrists to, for example, the secret police, in all its many manifestations in communist Russia, or torturers, and also because the content of one's work utlimately makes generalizations acceptable in a way that they would never be based on a link as tenuous as ethnic or religious identity, for reasons that should be self-evident.

If the institution is a rotten barrel, then all the apples it contains will rot. You may as well tell me not to generalize about executioners or slavemasters.

It is true that the work of state psychiatrists does not remain constant in all particulars due to historical, geographic and legal differences, and there have been epistemological shifts in the history of psychiatry, nevertheless certain aspects transcend these discontinuities.

Throughout the history of institutional psychiatry one of the main functions of the state psychiatrist has been to uphold the status quo and the interests of individuals and institutions implicated in the very suffering of the patient whose interests the profession purports to be the agent of.

Psychiatrists throughout history have also attached consequential labels to their patients for the purpose of social-control, the reverberations of which throughout the social, interpersonal, biological, mental and occupational spheres of the existence of the individual so-labelled can, in the aggregate, rarely be said to have been to his advantage. Indeed, it wouldn't be going to far I think to say that such diagnoses have resonated negatively and destructively throughout the lives of countless millions of people, rendered dispensable by psychiatric theory.

Coercion and violence, albeit concealed behind the bricks and mortar of the hospital and the idiom and imagery of medicine and medical practice respectively, have run like a thread through the historical tapestry of the profession, with psychiatrists having been granted dispensation, in the maintenance of the status quo and the war on heresy, to torture (historically the profession has drawn upon the state's wide-ranging repertoire of torture mechanisms, harnessing them to the purpose of modifying aberrant behaviour under the pretense of treating an illness) society's deviants and enemies.

For these reasons, and many more, I feel more than justified in my generalizations about state psychiatrists.

A man is the sum of his actions, because of the reciprocity of the relation between conduct on the one hand and our character and our ideas on the other. The character and the thought of the state psychiatrist is corrupt because his conduct is corrupt, conduct circumscrbed within the limits of the laws of his profession and his society and which he is duty bound to observe. This, further justifies genralization; complicity in the same crimes amongst a group of individuals often serves to unite them in thought, spirit, and character.

Mr Hassman really does seem to have an attitude problem. I find it very disturbing that patients have to deal with a person who responds so childishly to criticism (with adolescent sarcasm and the kind of conventional formulas one regularly encounters amongst the least sophisticated, puerile writers who sully cyber space with their splenetic effusions, seeking to compensate for the weakness of their arguments through sheer vituperation), unwittingly endorsing my belief that many psychiatrists are just intolerant control freaks who enjoy the heady stimulus their power affords.

Joel Hassman, MD said...

I do thank Dr Hickey for commenting here, he must realize by now I will not be back to the other blog he seems to write at with some regularity. Your reply is the most respectful and civilized of those who follow you with blind allegiance? I stand by my point of view, but appreciate you seem to relate there are others in my profession who do not worship at the aisle of "better living through chemistry".

Exiting from the profession will happen in 2018, and I have distanced myself from the mainstream while still practicing for years now, but I need an income right now, so I can't just sit in front of a computer screen all day and taunt colleagues and expect to feed and house my family. Not as lucky as some of the others here at this thread, I guess.

The other anonymous commenters who are solely out to bait and project, well, good luck with that, I have better things to do with my time. Strange you don't offer something at my blog.

To the last anonymous who calls me "Mr Hassman", your maturity and respect defines you in your writings. Still wish there was a sarcasm font.

Sorry Dinah, your blog risks the takeover other sites have unfortunately allowed in too much tolerance and over compassion.

Philip Dawdy of Furious Seasons had a somewhat decent site when I started commenting there back in 2009-10, and it regressed to ugliness beyond recognition, but, he admitted he wanted the hits and the action.

Which is what the trolls do at threads. See John Grohol's post from a few months ago at www.psychcentral.com/blog to document I am not making that up.

Hey, at least I admit who and what I am. There is only so much respect from being anonymous. Really, what do you folks fear from being a bit more transparent?

Oh, and which one of you anonymous folks wanted the thread back about medicating family? Or is it really words, not deeds that drive most of you?

Again, cheers.

Anonymous said...

Again, cannotsay here.

Joel,

You have an uncanny ability to always take your posts to inflammatory territory even when you seem more conciliatory. Take this,

"Really, what do you folks fear from being a bit more transparent?"

You see, for all your complex of feeling like a Jew prosecuted by Nazis, it is those of us have been labeled as "mentally ill" and abused by psychiatry (in my case, I was involuntarily committed and forcibly drugged) who DO HAVE to adopt the same tactics of anonymity that prosecuted minorities adopt everywhere, not only Jews in Nazi Germany.

As I said a while back, your profession might consider us "mentally ill" but it doesn't mean we are stupid :).

BTW, I am also glad to read that you admit to practice psychiatry now mostly for the money. Ie, you know you practice a quackery but you know you cannot be retrained to do something else that allows you to keep your current income level, so you do continue to do what you do with intention of quitting in 2018. I made this precise point -ie that those who defend psychiatry/psychology while admitting to its failings are basically defending their livelihoods- yesterday in the MIA post that you have pointed to in your website!

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Anonymous said...

The post is about a woman who wants treatment and cannot get it.

There is no reason to start ranting about psychiatry being quackery and so forth. My psychiatrist is no quack. That's unfair, and frankly it's rude. He is very judicious with medications and has always treated me with respect and kindness. I am lucky to have him as my physician.

I'm having trouble understanding why the comments have devolved into rants against psychiatry. Treatment has been helpful to Lucy. She wants treatment. What's to be angry about? She is not being forced to do anything.

Good grief.

P-K

Dinah said...

P-K: Me, too.

Borderline said...

PK: It is like I said. It's best explained as a math problem. Shrink Rap post+Joel inflaming readers=Angry anti-psychiatrists complaining about Joel.

Seriously, I know Joel complains on his blog that it's not his fault this stuff happens, and it's all these Axis 2 weirdos coming out of the woodwork causing issues...but at some point it needs to be acknowledged that he does attract these kinds of people. He goes on their blogs, provokes them, writes condescending comments everywhere he goes on the internet.

Regardless of whether everyone who argues with Joel is Axis 2 or not, he attracts those kinds of people like moths to a flame. And I will give them this, he is somewhat provoking them.

Dinah said...

I wrote about the responses to this article on CPN here:

http://www.clinicalpsychiatrynews.com/views/shrink-rap-news/blog/prescribing-psychotropics-to-family-members/de89a27dc297194d342d43f78da377c9.html

Anonymous said...

panic attacks , also
called anxiety attacks are a false triggering of the fight or flight response,
google fight or flight response for all the possible effects of it. panic
attacks often are inherited. they cant harm anyone so should not be feared. when
feeling stressed or panicky simply relax and breathe deep and slow. dont tense
up or fight back against it. do disolve any mid range valium type pill under
tongue for fastest help, google sublingually. agoraphobia is avoiding or
fearing places or situations likely to cause a panic attack. Ive found that the
best advice in overcoming both is in cheap self help books from internet
bookstores, order a few to be delivered to you by mail. therapists, especially
psychiatrists often give little advice and consider the panic attacks as
unimportant. they waste time and are often expensive, also their advice is hard
to remember as most patients are very nervous. valium type meds are still
the best for reducing or stopping a panic attack, if taken to hospital, the
usual treatment is an injection of valium. antidepressant meds help some a lot
but sufferers can have severe early side effects so start at much less than the
min dose range and slowly work dose up, google the antidepressant dose range for
guidance. valium reduces early side effects. antidepressants take from 2 to 6
weeks to start working and occasionally never help. the prozac or SSRI type are
popular but other types also help and so can be tried. older sedating
antihistamines calm some. valium type must be used sensibly but its been my long
experience that few sufferers have addictive type personalitys,t he main problem
being to get them to take a large enough dose rather than stopping them from
taking too high a dose the fight or flight response can become a strong
addiction, people activate it with dangerous sports, downhill skiing, bungee
jumping, parachute jumping, etc so some panic attack sufferers refuse to make
any attempt to recover or to take helpful meds. panic attack and agoraphobia
sufferers dont usually lead very stressfull lives. they become expert at seeming
calm and relaxed whan actually panicky I had panic attacks and severe
agoraphobia for 20 years before diagnosing myself and am now completely recovered

Steven Reidbord MD said...

I was reminded of this old post when I ran across this article recently in the New England Journal of Medicine:

http://www.nejm.org/doi/full/10.1056/NEJMsb1402963

Steve said...

Since I am not a doctor, but the son of a doctor, I can only speak based on lots of knowledge. Dad giving me Darvon samples or a valium in the 70's is different. Than prescribing Zoloft by any family member except to avoid symptoms of withdrawal. Zoloft is a fast acting SSRI. The sister was only on for a short time, starting a new dose is irresponsible without appropriate supervision eg Maniac episode, suicide, titration. Using narcotics is somewhat 19th century better than nothing. WHY FOR HIPPOCRATES SAKE HAS NO ONE GIVEN THIS WOMAN A BENZIODIAZEPAM. As a lawyer who understands these medications, my gut tells me not giving sister Xanax, which she had success with is far below the standard of care I expect and it doesn't take a psychiatrist (a doc in the box) to prescribe Xanax for a Panic attack. Compassion and Morality trump rules and regulations and protocols. The Zoloft could be dangerous. The benzos compassionate and safer than narcotics. Do no harm and do the right thing. If a doctor was not giving a family member of yours medication that you believe was warranted, you might suggest that they consider there responsibility under Tarazoff.

A Woody Allen movie had a funeral scene where there was a question because someone was having a panic attack. Anyone got any Valium? Docs if your children have toothaches an Advil doesn't work, give up something stronger. If your spouse is having a panic attack after a family funeral give em a benzo... 1. Do no harm. 2. Allievate pain. Great hypo. Sounds like Brother shrink may need a benzo.