Tuesday, February 23, 2016

What Your Psychiatrist Should Be Doing....

First, I'm going to send you over to read Pete Earley's blog post for today: Treatment Rather Than Punishment In Horrific Case But What Can We Do in the Future? 

So just to recap, this terribly tragic case is about a mother with schizophrenia who stopped going to treatment, became psychotic, put her three-year-old son on a swing and pushed the swing for 40 hours.  The boy died and the mother was found pushing her dead child in a swing.  The judge determined that she was not criminally responsible, and she is being mandated to treatment and allowed to stay in the community if she abides by the terms of her release.  This is an unusual outcome, usually if your child dies because of negligence or abuse, you go somewhere-- if not a prison then a forensic hospital.

So the question comes up as to whether this child's death could have been prevented, who is to blame, and how do we keep such things from happening in the future?  According to an article in the Washington Post, the mother had been admitted to a psychiatric unit in February of 2015, was discharged to outpatient care and was seen at a clinic in April of 2015.  She was diagnosed with schizophrenia.  She took medications and had stopped them only days before the tragic event in May.  The father had pursued full custody of the boy, but the parents ended up with joint custody.  The patient lived with her mother and son in a hotel. 

So Mr. Earley looks at the question of who is to blame. Is the adult patient's mother responsible? No, he contends, parents are limited in what they can do to help an adult child with a mental illness.  Should the hospital be responsible for making sure everyone goes to outpatient appointments months after discharge? No, that is too much to ask.  Social services? Too under-staffed.  And then I got to this sentence:

If someone is taking psychotropic medicine, the doctor who issued that medication should be obligated to monitor his patient.

What does that mean and how does that play out?  As a psychiatrist, when we hear the word "monitor," we think of assessing the patient to make sure the medication is appropriate, that side effects are being monitored (and hopefully minimized) and that recommended blood-work is being done.  I guess I could ask Pete what he meant by this, but instead I wanted to write a blog post.  It does seems like everyone else gets a pass -- the parents, the hospital, social services (~did they have a role?  Who exactly is social services anyway?).  But the psychiatrist should be obligated to monitor the patient.  No passes here.

So let's talk for a moment about the logistics.  A patient goes to a clinic and sees a psychiatrist and a social worker for therapy.  She stopped taking her medications, but there is nothing here about missing an appointment.  Should the doctor be watching patients swallow the pills?  Some people get sick even when they do everything the doctor says, our treatments help but they aren't perfect.  What if a patient who has been hospitalized doesn't show up at an appointment?  Actually, in community clinics, approximately 30% of appointments are not kept and it's possible that the doctor could be scheduled to see 12-25 patients each day.  He or she may call a patient who doesn't show up, but probably not-- it happens numerous times a day.  If a patient does not call to reschedule, eventually, the chart gets tagged, and the therapist calls or writes a letter to the patient saying that if he does not come in by a certain date, his case will be closed.  There is not a mechanism in our system for aggressive pursuit of patients. In fact, many clinics discharge patients if they miss 3 appointments in a row.  In outpatient settings, people are free to say they've decided they don't want treatment, they've decided to go elsewhere, they'll call when they want to come in. Just because someone has had an episode of mental illness-- one that required hospitalization-- it does not mean that we have a mechanism to insist they continue in treatment if they aren't in the criminal justice system --which this woman now is. 

What about Outpatient Commitment, or AOT as some call it -- would that have saved this child?  Well, we don't have it in Maryland, but even if we did, this parent was not repeatedly hospitalized, and she had voluntarily gone to care at the clinic the month before.  Even if we had laws for this, she would not have qualified.  And outpatient commitment is not a guarantee of safety: patients may disregard the orders, or get sick between appointments.

What about a system which includes very easy access to care and outreach service for all patients who have had an episode of illness severe enough to require hospitalization?  Maybe that would have helped, and if you agree, please do send your dollars to fund it because the expense would be astronomical. No where has this.

I don't know the details of this case and the press often reports selectively, so I don't even want to venture a guess as to what may or may not have prevented this tragedy.  I do think that there are some tragedies that we simply have no way of predicting.    

Sunday, February 21, 2016

Hotel California

Our group of psychiatrists have a listserv -- it's a wonderful tool for sharing resources and keeping everyone up to date about the latest in professional issues.  From time to time, a discussion will ensue, and one psychiatrist posted his thoughts about patients who want to change psychiatrists.  I thought our blog readers might want to weigh in, and with permission, I'm reprinting that doctor's thoughts.  

Regarding taking patients who want to switch doctors, I have my own particular thoughts about that. Psychiatrists are a very scarce resource these days. Therefore, people who are able to have a psychiatrist are the fortunate  ones. Also, like so many of us, I'm pretty booked so I do not have that many openings to take new patients. So I prefer to use those scarce openings for people who don't already have a psychiatrist. Also, people who want to switch psychiatrists very often are having difficulty communicating with their docs about what's not working for them in their treatment. Or, there are transference issues that have not yet been worked through. Or, any one of another impasses in the treatment alliance. Or, they are on an ineffective medication regimen and the treating psychiatrist hasn't been able to ascertain alternative approaches-- pharmacological or otherwise.  So, I am always available to do a one-time second opinion consultation for such dissatisfied patients. Those consultations  provide a diagnostic reevaluation,  perhaps new ideas about treatment alternatives, recommendations to enhance communication, and observation of psychodynamic issues that might be relevant to the stalled recovery and/or treatment relationship.  I identify aspects of their doctor's practice that could be modified to make for a happier patient (e.g.  returning  the patient's phone calls in a timely manner). I make my written consultation available to both the patient and the treating psychiatrist. I am also available to discuss the case with the current psychiatrist. But, I will not take the dissatisfied patient in transfer.  This is really no less than I would hope if one of my patients has been dissatisfied with our treatment and calls another psychiatrist  to jump ship and short-circuit the process of working it out with me.  I would hope  the colleague would respond in kind to what I have described.  Sometimes, that is been the case, but sadly other times it has not. Just like, sadly, sometimes my patients go to the ER and are hospitalized and  the treating docs there never call me.

I know another psychiatrist who once mentioned that he wouldn't take on patients who are already in treatment with another psychiatrist.  I didn't ask why, I just assumed he didn't like the idea of taking someone else's patient, that perhaps he thought it made for poor professional relationships.  

As you can tell from the title of this blog post, I don't agree.  I think if there are times when treatment comes to an impasse, and it just gets stuck.  I think there may be transferential issues to work through, but that should be the patient's choice.  Sometimes people are less concerned with issues in the therapeutic relationship and are more focused on concerns that they aren't getting better.  Some psychiatrists are better than others in general, and some psychiatrists are better than others with specific patients.  And psychiatrists offer different services: I've heard from many people who've tried med-check only treatment who come looking for psychotherapy as well how, "That fifteen minute thing doesn't work for me."  I'm also not so sure that because a consultant recommends that the treating physician should return phone calls in a more timely manner that it necessarily happens. 

Finally, the psychiatrist assumes that when the going gets tough, the psychiatrist wants to continue.  If a patient isn't getting better, or if therapy has become a war zone, then sometimes everyone agrees that it would be best for a fresh start.  Also, do remember that this is one psychiatrist's personal policy for his own private practice, and certainly, I believe doctors should practice in ways they find ethical and comfortable.  No one has actually suggested a true Hotel California policy where "You can check out any time you like, but you can never leave" and patients can never change psychiatrists.

At the other extreme, Roy once told me that if ever returned to private practice he would see patients for only one year: by that point they should be better or they should try treatment with someone else.  

I think patients should be able to change doctors -- of any flavor-- if they aren't happy with the care they are receiving. I didn't post this to poke holes: the psychiatrist above makes some very good points, and he does a nice job of putting into words what others may not verbalize as well.  His comments gave me the opportunity to think about this, so I wanted to give our readers the chance to ponder and discuss as well.  Note that comment moderation is off, so please do be kind to one another. 

Thursday, February 11, 2016

Interview with Touched With Fire Director Paul Dalio

A few weeks ago, I wrote about a screening I went to for the film Touched With Fire. 

 Last week, I had the chance to interview the film's director, Paul Dalio.  My article about the interview is over on Clinical Psychiatry News, so please click over there to read about this remarkable man and his new movie.  bit.ly/1SkleFU