Monday, March 30, 2015

What Adds Value to Mental Health Care? Looking for Your input....

I need  your help.  This year at the American Psychiatric Association's annual meeting in Toronto, I will be talking on what adds 'value' to mental health care from the patient perspective.  It's a symposium, and the other speakers will be approaching the issue from the perspective of the insurance company, the hospital, employers, and looking at things like quantifiable measurements of success measured with standardized tools and how to recognize waste in the systems.  I won't be talking about standardized tools.

So I need input.  If you're a  health professional and you've never seen a psychiatrist as a patient, please don't answer.  I want to hear what people see as 'value in mental health care' straight from a patient's perspective.  

Some possible questions include those below, but please feel free to tell me what you value about your mental health care.

  •  I'd like to hear what experiences and outcomes make you feel like you've gotten your money's worth?    
  • Why do you go to treatment?
  • What are you looking to get from it?
  • Do you have specific goals that you'd like to see measured by objective criteria?
  • Have you ever seen a psychiatrist for treatment, gotten better from your disorder, and yet not valued the care? Why?
  • Do you like that insurers and providers are looking at what makes for good value, meaning the best outcomes for the lowest cost?
  • In short: what makes for a good experience with a psychiatrist?  You can also tell me what makes for a bad experience.
  • While I've got you here, do you value having your psychiatric chart in an electronic medical record?

If you don't want to comment here, please feel free to email me at shrinkrapblog at gmail dot com.  

Sunday, March 29, 2015

"Mental illness" is not the Endpoint Answer to Why Someone Commits Mass Murder

Over on Clinical Psychiatry News, I wrote a an article about still-unfolding story of the Germanwings co-pilot who deliberately crashed a plane into the French Alps, killing 150 people.  Please surf over to read Was Mental Illness a Factor is the Germanwings Crash.   I'll warn you that the facts aren't all in yet, so the article is purely speculative, and it's possible we will never know why this co-pilot decided to crash this plane into a mountain.  I also tell you that as a psychiatrist, I don't know why someone commits mass murder; I've had no experience with patients who kill, much less kill 149 other people, nor have any of my colleagues or mentors.

Tawnydog1 may be right in her tweet above, the New York Times already has a front page article calling for  screening for pilot mental health issues.   Since the event of pilots crashing their planes into mountains is extremely rare (1 in many millions) and the pilot was said to have had an eye problem, I'm wondering why they aren't calling for better screening for eye problems?  Really, we don't know anything yet: we've heard nothing about the stresses in this man's life, whether he was telling friends and family that he was having delusions, why he took time off from training, what his illnesses were, and how he dealt with anger.  

I'm going to go out on a limb here: people commit suicide for a number of reasons, one of them being a way to escape the unbearable pain of depression.  People kill for a number of reasons, one of them being because they are angry.  There are many mentally ill people in the world and there are many angry people in the world.  There are very few mass murderers.  We need to stop using "mental illness" as the endpoint to answer the question "Why?" when a mass murder happens.  Mental illness is not an explanation, and this may be a problem that is so rare that there will never be a reasonable response to this event other than to say that for any number of reasons, pilots should not be alone in the cockpit of a commercial passenger plane.

Saturday, March 28, 2015

Resilience: Two Sisters, Mental Illness, A Trust Fun and Quite the Ride

Resilience: Two Sisters and a Story of Mental Illness is a memoir written by Jessie Close with journalist/advocate Pete Earley, plus a few 'chime in' chapters written by Jessie's actress sister, Glenn Close.  

So let's start with family history.  It's a good place to start and we learn that the Close sisters come from a line of those who were rich, famous and colorful -- ancestors with names like E.F. Hutton and C.W. Post.  Not to mention great-uncle Seymour who thought he was a German spy then took hostages at gunpoint and had his chauffeur drive them home.  

Close describes a happy childhood living on her grandparents' estate in Greenwich while her father remained in Manhattan for his surgery residency.  Happy, until her parents joined the Moral Re-Armament or MRA, a religious cult.  From there, the family began to fracture.  First, it was just the parents who left and MRA nannies raised the children,  but then the family moved to MRA-run estates in New York, then Switzerland, and finally Jessie -- the designated problem child-- joined her parents in Africa.  She describes a lonely, chaotic childhood marred by anxiety and abandonment. 

From here I'll avoid plot spoilers and just tell you that what follows is a story of sex (and more sex), drugs, alcohol, as well as some rock & roll with much of the compulsive energy being explained by either mania or depression.  There are five marriages and three children, countless houses, cars, and dogs,  and a diagnosis of bipolar disorder along the way.  Jessie eventually lands in a place where she is more comfortable, balanced, and in control of her emotions and behavior. 

Psychic peace, in this case, comes at a price.  Recovery is not a smooth road for Jessie and in giving up her mood swings, my sense was that Jessie lost a part of herself.  So if you worried that this would be a placating story of how psychiatry is all good, rest assured that the author has her share of rare adverse reactions to psychotropic medications, not to mention a struggle with medication-induced weight gain which she minimizes.  In the end, she finds solace in her own company -- something she seemed to find unbearable before -- and decides that she needs to forsake romantic relationships.  These tradeoffs are those a person will  make only when their pain is unbearable.  

The bottom line on the memoir: two thumbs up.  The book is a quick read as Jessie Close pulls you on to her roller coaster ride of a life with severe, unremitting mood swings.   

Sunday, March 15, 2015

How Was Your Stay in a Psychiatric Hospital? -- Please Take My Survey: 5 quick questions

I'd like to tell you something.  The comments we get on this blog, especially lately,  talk about how horrible it is to be treated in a psych unit.  People say they would rather die then go back, they're infantilized, demeaned, and sometimes people describe frank abuse. They deem it comparable to rape and torture.  In my all-voluntary outpatient practice, I treat patients who sometimes get hospitalized and I make a point of asking people about their experiences.  People end up in psych hospitals during miserable periods in their lives, so it's never a happy issue, but unlike our blog commenters, my patients often say the  hospitalization was helpful, that people were kind to them, and that they left in a better state.  I don't work in the hospital and I generally have open and warm relationships with my outpatients -- who know I don't have anything to do with inpatient units -- so I'm thinking that perhaps they aren't lying out of fear of retribution if they are readmitted.

Let me add something else, the two biggest psych units near me are rated in the top ten in the country.  This may well be a skewed sample.  Few people go to state hospitals in Maryland for routine psych care-- the state hospitals are mostly for forensic patients and the state leases out short-term beds in community hospitals for the uninsured.  There are still a few long-term patients in the state hospitals, but not a lot.  And the chairman of my residency program made a point of asking every patient he interviewed if they were being treated well; The patient might be afraid to say they were treated meanly by a nurse, but the nurse would be even more afraid.  And please don't think that means that no one ever muttered an insensitive word to a patient or did the wrong thing, but I do think most patients there thought it fell short of torture.  In urban areas, many are looking for "three hots and a cot" and the hospital often fills that roll.  And some of the units attracted patients from all over the country who really, really wanted to be there for relief of their torment.

I'd like to know about your experience if you've ever been treated as an inpatient on a psych unit.  Will you take a quick survey for me?  And please -- this isn't science,  it's not validated -- but please just answer one time and one time only. And thank you so much!

Thursday, March 12, 2015

How Psychiatrists Spend Their Time and Why the Agency Demands Contribute to the Shrink Shortage

Over on Clinical Psychiatry News this week, I wrote an article called Addressing the Psychiatrist Shortage: What Keeps us from seeing More Patients?.  Please check it out and tell me what you think. 

Tuesday, March 10, 2015

Responding to the reaction to Are There Ways To Lessen The Violation That People Feel After Psychiatric Hospitalizations? Polarized responses!

I saw the Mad in America article about my post on

Are There Ways To Lessen The Violation That People Feel After Psychiatric Hospitalizations?

 I feel like it was misrepresentative to say that I wanted to give people cake and ice cream, as if that would undo the violation people might feel, especially after involuntary hospitalizations.  I was drawing on the example of what I saw in mental health court, that people who were incarcerated as criminals, then chose to participate in the MHC with all it's requirements (generally many: treatment, medications, often substance abuse treatment, requirements for day and residential programs) yet  end with a sense of being proud.  There is a graduation ceremony and they come if they want, invite their families, get certificates, take photos with the judges.  No one is forced to come, and the have fried chicken --which I somehow found humorous, but at the moment it's looking a lot better than the cake and pizza which are my favorite cheap foods.  Readers felt was demeaning and comparable to birthday party food for small children, and if I ever suggest food again for any event, it may be lobster.  I was trying to say that if something presumably traumatizing -- like getting arrested and labeled a criminal -- could later be turned to something that wasn't so shameful, maybe we should consider that sort of thing to help people feel less traumatized and shamed with hospitalization.  Without the mention of Mental Health Court's approach, it comes off as sounding like I want to feed people cake to make their pain go away and undo the violations they were subjected to, which I never meant.  I wanted just to ask if people felt that some validation of their distress would be helpful, and I think people like food with events. Or at least I like food with events.

I realize that some people who are involuntarily hospitalized are terribly traumatized, which is why I'm writing the book.  I don't think psychiatrists see that and I think if it were figured it into the equation, maybe less people would be involuntarily hospitalized (certainly, no one should be forcibly hospitalized for 'sadness' as one of the MIA commenters put it), other alternatives could be found, and more of an effort would be made to treat those where there are no options but involuntarily hospitalized with respect and kindness.  I thought the responses were polarizing, while commenters here and at Mad in America complained that I was lacking empathy, defensive, and just plain evil, Psychiatric Times deemed it one of the top 6 articles on psychiatry for the month! 

Monthly Roundup: Top 6 Psychiatry Articles in February

Monthly Roundup: Top 6 Psychiatry Articles in February

- See more at:

Monthly Roundup: Top 6 Psychiatry Articles in February

Monthly Roundup: Top 6 Psychiatry Articles in February

- See more at:

Monthly Roundup: Top 6 Psychiatry Articles in February

Monthly Roundup: Top 6 Psychiatry Articles in February

- See more at:
I stopped publishing the comments on my own blog, because as horrible as I hear people can be treated during involuntary stays, these feelings are not the same for everyone, and the comments because insistent, repetitive, and I don't think they left room for anyone to voice another opinion .  Some people get better and appreciate being in the hospital, some get better and still understandably resent it, and some are just terribly distressed for years.  When they get too extreme, I worry that people stop listening -- so while I know people feel terribly violated, I wonder if it wouldn't upset the victims of war torture, rape, and kidnapping, to have their experience compared to being in the hospital where people presumably are at least trying to help them?  And I think some people shut down when they hear someone compare treatment to torture -- there are those who will stop listening and discount their opinions. We live in a democracy, and I think folks might get more traction by talking with their legislators and proposing new laws; it's more powerful then blog comments.  And most psych hospitalizations are voluntary -- some coerced, but many people ask to be in the hospital, repeatedly, and find it helpful.

  I'm sorry this blog post turned out to be so polarizing.  No one has ever called me "evil" before.  And one commenter on my blog (unpublished) insisted psychiatrists just need to admit that their work is useless and never helps anyone and that I should become a gardener.  If it doesn't help you (and I mean the metaphorical 'you', not you personally!) then I can see why you might think that, but it seems unfair to insist that everyone has the exact same reaction to being hospitalized, or even being offered outpatient psychotherapy on a voluntary basis.   I'm also sorry that some of my comments came off as being defensive. Often I'm responding to blog comments quickly, between activities, and I often don't measure every word or consider how they might be construed from a variety of different perspectives.  Anyone who regularly reads my blog knows that my posts are done quickly and often with typos, I'm just stretched a bit too thin to do the proof-reading to catch them, and in a similar way, I sometimes reply to comments without thinking through every angle.  I also often have completely different views than the commenters.  And I admit that I do close up a bit when people insist that everyone experiences things the same exact same way that they do.  It leaves no room for people to be human.

Hundreds of thousands of people are involuntarily hospitalized each year.  While I won't be suggesting acknowledgment events in the book after the feedback I've gotten, I do wonder if just one of those hundreds of thousands of people might like someone to notice how painful their experience was and how hard they worked to get better, and perhaps be offered the chance to have their kids come have a piece of pizza with them when they were ready to go home. 

I am well aware that offering someone a "party" or a piece of cake doesn't make the bad of it go away and I never intended that.  There are some people who come in very sick and very psychotic, and who feel a lot better.  And by the 'exit interview' I was thinking some about the comparison to being raped -- -what could be worse than being raped and having someone tell you it didn't happen or wasn't that bad?  Might it help to be heard and have your violation acknowledged?  I hear that some people feel that wouldn't be safe and that if they were ever admitted again, they could be the subject of retribution.  I never meant for either an exit interview or a the offer of an acknowledgement meeting to be something that is forced, simply offered.  Sometimes it seems our commenters pit the patient as always the sane one -- as though people can never be sick or psychotic, or dangerous, or violent-- and the staff as purposely sadistic.  Patients can be sick, and there are bad people in all fields And believe me, I feel anyone who is intentionally cruel should be fired. 

Please feel free to post this in the comment for me on Mad In America.  Commenting here will be closed for a bit.  

Tuesday, March 03, 2015

Big Girls Don't Cry. Take a Pill.

Updated for typos!
In Sunday's New York Times there was an interesting article by Dr. Julie Holland about how women's emotions should be appreciated and not pathologized.  

First, let me tell you that I read Dr. Holland's book called Weekends at Bellevue and I hated it.  She talked about her sadistic feelings (and sometimes actions) towards patients, and her own therapy to overcome this.  While I realize that we don't all harbor the kindest feelings towards every single patient on every single day, and sometimes docs have rough stuff going on too, I was appalled.  She whistled some song about here comes the parade when prisoners were brought into the ER.  She was mean and disrespectful.  Feelings are feelings, but to knowingly be sadistic and disrespectful to patients is inexcusable. I read it and was embarrassed to be a member of her profession. 

Now that I got that off my chest, the article in Sunday's NY Times called Medicating Women's Feelings was interesting and thought-provoking.  Holland writes:

WOMEN are moody. By evolutionary design, we are hard-wired to be sensitive to our environments, empathic to our children’s needs and intuitive of our partners’ intentions. This is basic to our survival and that of our offspring. Some research suggests that women are often better at articulating their feelings than men because as the female brain develops, more capacity is reserved for language, memory, hearing and observing emotions in others.

These are observations rooted in biology, not intended to mesh with any kind of pro- or anti-feminist ideology. But they do have social implications. Women’s emotionality is a sign of health, not disease; it is a source of power. But we are under constant pressure to restrain our emotional lives. We have been taught to apologize for our tears, to suppress our anger and to fear being called hysterical.

Dr. Jeff Lieberman, the past APA president tweeted that the article was 'anti-psychiatry.' I didn't see it that way at all.  Holland talks about how anti-depressants clearly help some people, but she also discusses the high numbers of women who are treated with them.  It's an issue we've  discussed many times here on Shrink Rap:  our illnesses are syndromic, they are decided by committees (with the help of research), but they can be inexact.  Say you need 5 symptoms for 2 weeks to meet criteria for depression, and a patient comes in with only 3 symptoms for 10 days, but those three symptoms include profound sadness, suicidal thoughts, and a loss of appetite, I don't believe too many psychiatrists are going to stand there with a check-list saying, nope, you need 4 more days and 2 more symptoms before we can call it depression, come back then.  

Was the article right?  Was it just plain sexist?  Are women moodier than men and is treating this a form of suppression?  I am certainly moodier than my husband.  But everyone I  know is moodier than ClinkShrink and she's a woman.  Should we accept and celebrate, depression in women, but not in men?  Are some people over -diagnosed and over- medicated? Who is to be the  judge of that if a patient says 'Look, this medicine helps me feel better'?  Or are there people who are under-diagnosed and under-medicated?  I suspect the answer is 'All of the Above,' and I still go with the idea that if you show up at my door and say you're suffering, and you want to try meds, I'm usually fine with that. But before you knock, know that I will also insist on therapy, at least at the beginning of treatment.

So I think questioning is fine.  What is the role of the pharmaceutical companies in deciding what's an illness and what we treat?  Do we under-diagnose or over-diagnose?   
Emotions occur along a spectrum and they come and go over days or hours if not weeks or months.  It's not anti-psychiatry to be skeptical or to question.  And debilitating mental illness is not subtle. I do believe it's the subtleties, the symptoms that come and go in someone functioning normally that Holland may be talking about.  

What do you think? 

Saturday, February 21, 2015

Are There Ways To Lessen The Violation That People Feel After Psychiatric Hospitalizations?

In last week's New York Times there was an article with a rather interesting title: "Doctors Strive to do Less Harm by Inattentive Care" written by Gina Kolata.  The amazing idea here was that doctors should spend some time listening to their patients (~as an aside, I am so very glad I'm a psychiatrist/psychotherapist), and doctors should acknowledge that people in hospitals may be suffering, not just from their illnesses, but perhaps also from the insensitive treatment that has been inflicted on them such as 4 AM blood draws and unnecessary noise.  Kolata writes:

They found several categories. Communications — for example, a doctor blurting out, “Oh, it looks like you have cancer.” Or losing a valuable, like a wedding ring. Or loss of privacy — a doctor discussing a patient’s medical condition where an adjacent patient could hear.
“These are harms,” Dr. Sands said. “They elicit suffering. They can be long lasting, and they currently are largely unquantified, uncounted, unrecorded.”

So let me tell you why this article caught my attention, and how I'd like your help and input. Bear with me for a little bit here.

As our readers know, we're working on a book, Committed: The Battle Over Forced Psychiatric Care.  In my research on involuntary psychiatric care, and even on coerced care and some voluntary care, I've heard people talk about how traumatizing treatment can be.  Not everyone says this, not even most people, but some people are very sensitive and some care is very callous.  I'm finding that a little of the care is unnecessarily brutal, but this has really gotten so much better in recent years.  People are rarely restrained in your average psychiatric unit (I've been peeking in mostly empty seclusion rooms and asking lots of questions), because regulations restrict this.  But sometimes it really is still necessary; as much as we like to say that psychiatric patients aren't dangerous, some are.  Some kill people, and psychiatric hospitals are not necessarily the safest places to be.  In one forensic hospital in our state, in a one year period, three patients were killed by other patients.  In one community hospital, a patient poked out the eye of a nurse.  Staff are assaulted regularly, and even our own blogger ClinkShrink was punched in the head by a patient who had no prior contact with her and no reason to assault her as she was leaving the unit.  Clink was this patient's second assault victim of the day.

But let's move away from the extreme cases of violence.  Patients are traumatized by more benign things --- being asked to participate in activities that don't feel therapeutic when they are feeling miserable and depressed and would rather stay in bed.  Having nurses shine flashlights on them to tally their hours of sleep.  A lack a of privacy and a constant sense that they aren't trusted.  What? I can't have a belt on the unit?  I like my pants to stay up! Patients don't control the temperature of the rooms, the volume or programing of the TV, what foods they are fed, when they can exercise, when they simply take a walk outside, if they can have wine with dinner, a smoke after, and sex when the urge strikes with an appropriate love partner.  They may not know what the consequences might be for refusing to swallow a medication that makes them nervous to ingest, and there are circumstances where are injected with medications against their will.  They may find treatment to be very disrespectful and very demeaning.

Some of these things have no great answers.  The staff can't magically predict who is dangerous and there are sometimes concessions to comfort and human rights. Obviously everyone isn't held in restraints because of what they might do, and people are allowed to leave the unit and usually nothing bad happens --but believe me, everyone remembers when something really bad does happen.   

Many of the patients leave the hospital so much better.  Their depression has started to lift, their agitation is quelled, they aren't suicidal, they aren't terrified of delusional events that were never happening or hearing voices that aren't there.  They're sleeping and eating better and not so irritable or not so manic as to be uncontainable.  And yet, these so-much-better people, some of them feel so violated and so angry about what has transpired in the name of getting them help.  Maybe it's all a lack of insight, but I want to wonder if it's more than that, and this where I'd like your input.  As with the cancer patients Ms. Kolata wrote about, it's a field with so little research.  People are very different, and we simply don't know who gets distressed and what might mitigate that distress.

This is what I wonder.  Would it help to have an exit interview?  To listen to what of the treatment made patients suffer.  To listen, not to to throw in people's faces that it had to be done because they were embarrassingly out of control, but to acknowledge that the treatment was difficult, hard to endure at times, and to simply validate the distress the patient felt without the assignment of blame to either party?  

I'm going to go one step farther, please hang in here with me.  I recently spent a day with a wonderful mental health court judge.  If you know nothing about mental health court, the short version is that some people with psychiatric disorders are offered the opportunity to plead guilty and participate in mental health treatments, and if they do so successfully, they can avoid serving time in jail.  In some cases, their record can be cleared.  So these are people who have committed crimes, but the team is like a hospital team -- social workers, prosecutors, defenders, the most amazing of probation officers, and comprehensive services are put together to include drug treatment, clinic appointments, vocational rehab, housing, and weekly check-ins with the probation officer who talks to everyone from the patient's psychiatrist to the patient's mom.  It's the legal system taking over a medical role but the person at the head of the table is a judge and not an attending psychiatrist.  I'll tell you that I found it really weird.  And so you know, this is behind the scenes, it's not a public discussion.

Later, however, there is a quick public court hearing.  The defendants come to court once a month (or more) and if all is going well, the court has a celebratory feel.  There's a quick report and the judge congratulations the defendant on a job well done.  There may be applause, there may be certificates, the defendant is asked if he has anything he wants to add, and a subpoena is given for the next month.  These are criminals, and yet their successes (which are simply the lack of more failures and compliance with recommended treatments) are being celebrated and publicly acknowledged. Every few months, there's a graduation ceremony for those who finish the terms of their is served, families come, boyfriends and girlfriends come, photos are taken with the judges.  It's all good, people are happy and they've been given the opportunity to get treatment and turn their lives around.

So would it help when people left a psychiatric hospital feeling badly, violated perhaps, and certainly shamed because this is something we hear over and over even if the patient did nothing shameful at all, if we listened?  What if we acknowledged how difficult it can be to get treatment and participate in it, to let people know what a tremendous job they've done in getting through such a difficult time (even if it wasn't all graceful)?  Would it help to have a celebration when someone was discharged --even if just pizza or cake or something a little healthier, but to bring in family and print up a certificate to be read aloud and not make this all about shame?

Obviously it might be nice, but what I want to know is would there be a reasonable shot that this might mitigate the trauma of the hospitalization?  That it might lessen the sense of violation and reduce the idea that if an illness remitted and another hospitalization was needed, that it wouldn't necessarily be all that bad?  I'd love to hear what you think, and if I'm wrong about this, I'd love to know what you think might make for a easier re-adjustment with less dwelling on the injustice of it all?  And yes, this time, I'm more interested in hearing from patients who've been hospitalized.  Thank you so much.

Sunday, February 08, 2015

On Government Oversight and Caring for the Sickest

This is going to be another post on the issue of "Us" versus "Them" because that seems to be what psychiatry is about these days: civil wars. 

First, I'd like send you over to an article in the Wall Street Journal by E. Fuller Torrey and Doris Fuller: Mentally Ill?  Drink a Smoothie.  Torrey and Fuller run the Treatment Advocacy Center-- it's known for for it's vigorous support of legislation that would increase the use of involuntary care for those with severe mental illnesses.  It's one part of their work, and their overall mission is "to eliminate barriers to the timely and effective treatment of severe mental illnesses."  

Torrey and Fuller write a scathing article about SAMHSA --The Substance Abuse and Mental Health Services Agency-- our government's oversight agency.  They point out that of SAMHSA's 570 employees, only one is a psychiatrist who works with the substance abuse side, not the mental health segment.  They point out that the agency's 41,800 word action plan doesn't include a single mention of 'schizophrenia' or 'bipolar disorder.'  Worse, they describes how there is little or no coordination between programs targeting serious mental illness.  The graphic at the top of this post, by the way, is a children's book funded by SAMHSA.  Your mental health tax dollars at work and I'll leave you to decide if that's how you want them spent. 

Torrey and Fuller write:
 The nonpartisan Government Accountability Office this week released a scathing report on the lack of leadership in the Department of Health and Human Services for coordinating federal efforts related to serious mental illness. It described 112 separate programs in eight federal agencies with little coordination. “The absence of high-level coordination,” the GAO concluded, “hinders the federal government’s ability to develop an overarching perspective of its programs supporting and targeting individuals with serious mental illness.” The report was especially critical of the lack of any formal evaluation mechanism for the majority of the programs, so there is no way to tell whether they are working.

They go on to say: 
Meanwhile, problems related to serious mental illness have continued to get worse. Such individuals comprise at least one-third of the homeless population. And according to our analysis of data from the Justice Department, American Correctional Association and the American Jail Association, there are now 10 times more people with serious mental illness in U.S. jails and prisons than in state mental hospitals. Individuals with untreated serious mental illness are responsible for 10% of all homicides in the U.S. and approximately half of all mass killings.
And what has been Samhsa’s response? In September the agency sponsored a “National Wellness Week” during which it suggested that drinking fruit smoothies and line dancing would achieve wellness. And during last month’s “historic” East Coast snowstorm, SAMHSA opened four hotlines for individuals worried about the storm.

Regardless of your feelings about Torrey's work on involuntary treatment, when it comes to issues of how the government is funding and administering care in a timely and effective manner, Torrey is right: the money could be put to better use, we need more effective and timely --and I'll add kind and humane -- treatments for those with mental illness. You'll note that I have omitted the word 'severe.' 

In another article on therapeutic communities, Allen Frances noted, "Advocacy for the mentally ill has been so ineffective in part because it has so split in the often bitter civil war between the medical model and the recovery model."

So this 'civil war' that Frances refers to has been played out in our federal government.  SAMHSA has largely taken on a 'Recovery model' stance, and not a 'medical model' one.  The Recovery movement is, in part, a backlash to conventional psychiatry with opposition to the idea that psychiatric diagnoses convey hopelessness and are dis-empowering, and that psychiatric treatments have been harmful and disrespectful.    The Recovery folks are worried that those who favor the medical model will de-fund (?un-fund) their programs, and they well be right to worry.  There has been a push-back against the Recovery model from people who note that not everyone gets well and that some people do need a more paternalistic doctor-knows-best treatment model focused on medications and illness.  They further feel that the Recovery model conveys blame on those suffering from psychiatric illness -- if only you tried hard enough (and drank smoothies) you, too, would heal.

There's an underlying civil war going on as well, that sort of falls along the lines of Recovery vs. Medical Model but not exactly.  It's the Robin Hood civil war, held by TAC and D.J. Jaffee's, the one says stop worrying about those with mild mental illnesses, the so-called 'worried well,' and move the resources to those with severe mental illness, a very small but very sick percent of people with greater needs.   

I've made the point many times that there is no Us versus Them when it comes to mental illness.  I've run a survey showing that we don't have a clear consensus on who these mentally ill people are (results here)  and in my satire post last week about identifying the mentally ill for purposes of gun ownership, I noted that they don't wear signs on their heads.  Torrey, however, is a schizophrenia researcher and his interest is in patients with chronic psychotic disorders; these people sometimes do wear signs on themselves -- the layers of dirty winter coats they wear in the summer or those who are obviously psychotic who live on the streets and move in and out of jails and hospitals.  Those are the people he cares about.  The suicidally depressed executive who never misses a beat at work,  who goes for therapy and a Prozac script, then has a full recovery within weeks, and quietly goes about living his meaningful life -- he is not Torrey's patient.  

I'm going to contend that Dr. Torrey is right about much of this.  We need more efficient oversight and we psychiatrists involved at the high levels of administration, and we don't need to be funding hotlines for people anxious about snowstorms -- the truly distraught can call the existing suicide hotlines.  We need to include those with severe mental illnesses and to make provisions to help them lead meaningful lives.  

At the same time, I'm going to contend that we can't be Robin Hood, taking from the not-so-sick (those damn worried well who use up society's resources because they can't pull up their own bootstraps)  to give to the sickest.  If a teenager  commits suicide as an impulsive act because he's upset about a break-up with a girlfriend, he's just as dead as a person with chronic, unremitting bipolar disorder who commits suicide.  Someone can be in a crisis that is not mitigated by psychosis or severe mental illness, and that crisis can lead to inability to maintain jobs or marriages or even life itself.  And while half of mass murders --as Torrey tells us - and 10% of all murders are committed by those people with mental illness, then half of all mass murders and 90% of all murders are committed by people without a diagnosis of a serious mental illness.  It's hard to imagine that someone who kills a group of random strangers isn't disturbed in some way, even if they don't fit into the neat little DSM check-off lists.

We need to end the divide between the Recovery and Medical models and have our joint goal be to help people get better -- on their terms and with engagement and respect, whenever possible.  

We need to have timely and effective mental health services available to everyone in distress, whether or not they suffer from psychotic disorders. Clearly, there are people who come for a session or two and the crisis passes, they get something out of it, and they move on without tragic sequelae.  And there are those who need lifetime treatment with expensive medications, help with housing, regular appointments, case managers, daily rehab programs, and a lot of investment.  They should have that, too.  We have plenty of people to spend money on, but what we don't need is more government officials to administer uncoordinated agencies with costly infrastructure that takes money away from providing services to all who need them.  This needs to be our Us against Them: more care/more research vs. less redundant, inefficient beaurocracy.    I'll leave it to you to decide if a smoothie will help.

Wednesday, February 04, 2015

Links You'll Like

From my twitter feed: 

First, my column on Clinical Psychiatry News expressing my displeasure that APA is supporting The Helping Families in Mental Health Crisis Act. 

Lithium in drinking water significantly lowers suicide risk in men:

Great explanation of NNT --Number Needed to Treat-- versus NNH -Number Needed to Harm.  

Serotonin receptors, explained.   

And the psychiatric quote of the day goes to Allen Frances for, "Advocacy for the mentally ill has been so ineffective in part because it has so split in the often bitter civil war between the medical model and the recovery model."  Read his article about a therapeutic community here, and by the way, I'd like to register to live there -- not as a doc, but as a patient who wakes up to a day of organic farming, exercise, art... sounds nice.  The quote was too long to tweet.
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:
Advocacy for the mentally ill has been so ineffective in part because it has been so split in the often bitter civil war between the medical model and the recovery model. - See more at:

Tuesday, February 03, 2015

Does "coming out" with your psychiatric diagnosis help?

So I'm sending you over to read  a wonderful piece in the New York Times by Scott Stossel,  'Coming Out as Anxious." 

The author wrote a book on anxiety and he discusses with his therapist whether it might be therapeutic to tell the world about his problems -- would it lessen his anxiety if he didn't have to spend so much energy pretending it wasn't there, making excuses, and covering for it?  He tells a good story.  

My psychotherapist, Dr. W., understood my concerns. But he suggested gently, on many occasions, that revealing my anxiety would perhaps dissipate the shame I associated with it. Doing so might prove therapeutic, even liberating. “You’ve been keeping your anxiety a secret for years, right?” he would ask. “How’s that working out for you?”
He had a point. I was still terribly anxious, and often unhappy.
But I would retort that at least I was gainfully employed and not a laughingstock or an object of unwanted pity. Concealing my anxiety was in some sense working for me.

Dr. W. would counter that by sharing what I had gone through, perhaps I could provide solace to some of the millions of other people who suffer from clinical anxiety. Perhaps I could even, as he put it, “write yourself to health.”
In the end, I decided, with considerable apprehension, to go ahead and reveal my own anxiety in the book. It’s now been a year since my book was published. Did “coming out” help?
The short answer is: a little bit, yes. The longer answer is … well, let me tell you a story.

Couch is a series about psychotherapy  .Couch

Saturday, January 31, 2015

The APA and The Helping Families in Mental Health Crisis Act

If you are not familiar with Representative Tim Murphy's legislation to overhaul America's broken mental health system, this post isn't for you.  The legislation died when congress convened, but Rep. Murphy is planning to reintroduce the legislation to this congress, and he has 115 co-sponsors for the bill.  In the last session, APA took no stance on the bill; they wrote a letter supporting the idea of legislative change and said they looked forward to working with Murphy on this.  Rep. Murphy has said that the new legislation to be proposed will have some changes, changes that APA finds more in alignment with member concerns, such as an effort to increase the mental health workforce (I believe through tele-psychiatry) and to increase the emphasis on parity.  The bills requirement that every state have an outpatient civil commitment program may include funding to other types of treatment such as mental health courts, and I'm not aware of any changes to the idea that HIPAA privacy rights to patients will be modified such that mental health professionals will be permitted to communicate with caretakers of people with severe mental illnesses if it's felt to be necessary for the patient's safety or welfare.  While the text of the bill has not been released yet, the APA has come out in support of the soon-to-be proposed legislation.

I was disappointed to see that APA supported this, and I'm planning to write an article on it.  If you're a psychiatrist and an APA member, I'd love to hear your thoughts and possibly quote you.  Feel free to comment here, or to contact me at shrinkrapblog at g mail dot com.  And as always, everyone's thoughts are welcome.  

Friday, January 30, 2015


Wishing you a wonderful weekend.  Tigermom and her blogging friends sent this to me this morning and I thought I'd share it with our readers.

Monday, January 26, 2015

A Quick Guide to Identifying the Mentally Ill for Puposes of Preventing Gun Violence.

I often hear people talk about how we have to keep guns away from the mentally ill.  A judge friend recently said it quite bluntly, "What's the issue with guns and the mentally ill?  They shouldn't have them." A cousin posted a link to a story about a man who killed his family and then himself.  Cousin commented, "We have to find a way to keep guns from the mentally ill."  The article mentioned nothing about a history of mental disorder or psychiatric treatment or distress in the man who killed his family and himself; people were shocked, there was no clear motive, the gun was owned legally.  Granted, by the time you kill your family and yourself, there may well be a mental illness leading you to this, but people say "Keep guns from the mentally ill" as though they wear signs indicating who they are.  Sometimes, the first clear indicator that mental illness is present is an act of violence, often a suicide attempt or worse, a completed suicide.  It's all awful.

So I thought I would help here with some guidelines as to how to identify those with mental illness so we actually can do a good job of getting their guns.  Here would be my criteria for labeling people so that we could prevent mass murders and other atrocities:

~Anyone who has a been civilly committed to a hospital for a suicidal or violent act.
~Anyone who has been civilly committed for threatening such things/ saying them/ or thinking them.
~Anyone who has been voluntarily in a psychiatric unit, even if not acutely dangerous right now, there is clearly a mental disorder present.
~Anyone who has seen a psychiatrist or therapist. To get reimbursed for these services, you need a DSM code to submit, so all these folks are mentally ill.
~Anyone on Social Security Disability for a psychiatric reason.
~Anyone who has gotten a psychotropic medication from a primary care provider, a psychiatric NP, or any other prescriber. Purchase of any psychotropic medication should immediately trigger notification of the FBI.  Remember, some anti-convulsants are prescribed for psychiatric reasons, so prescriptions will need to show clear indications for the medications.  The pharmacists will have a dedicated line.
~Anyone who has taken a sleeping pill, because sleep problems are often secondary to other psychiatric conditions, plus they slow reaction times and can cause cognitive issues.  We don't think people under the influence of sleep medications should be operating guns, do we? 
~Anyone who purchases over-the-counter sleep medications, or any medication that can induce drowsiness. If you need to be drugged with something that warns against operating heavy machinery, the FBI needs to know and you don't need to be pointing a gun at anyone.  Plus, do we really want people who are sleep deprived to be handling guns?  They can be very cranky.
~For the same reason, anyone who takes narcotics for pain, coughs, or recreation.  Or amphetamines for that matter -- they make people jumpier, not a good mix with a gun.  And testosterone makes people more aggressive, so that should be a no-no.  Need a mood supplement: St. Johns Wort or SAM-e?  The government needs to know.   
~Anyone who tells a health professional about mood changes, feeling sad or stressed.  This could be a warning sign that a mood disorder is present and you never know when someone might swing to being a killer. 
~Because many people with mental illness never seek treatment, we need a list of psychiatric symptoms to be made public, and all teachers and employers should be required to report when they hear of, or observe, any of these symptoms.  Voices, paranoia, moodiness, irritability, anxiety?  There should be mandatory reporting with stiff criminal sentences for any health care provider, teacher, coach, or employer who does not report the name of anyone with psychiatric symptoms to a federal gun database.
~Google searches should be monitored for those looking up mental disorders or psychiatric symptoms.  Facebook/Twitter/Instagram posts should also have identified phrases that are associated with mental illness.  Those teens who post song lyrics about existential angst or the end of the world -- the government needs to know. 
~Substance abuse is a mental illness, and guns and alcohol/drugs don't mix.  They are a recipe for disaster.  Liquor stores should have a threshold amount for purchases, along with requisite questionnaires to determine who is drinking too much.  Case of beer for the Superbowl?  List the names and addresses of who those who will be sharing with you and the predicted number of beers/person.  Unused portions along with accountability charts need to be returned so those who over-imbibe can be identified.The government needs to know.
~Reclusive and weird: absolutely no gun.  The government needs to know about anyone who isn't out of their house by 9 AM on weekdays.  Special dispensations could be issued for people who work at home or have unusual hours, provided they do leave their house for enough hours/week and have a threshold number of social contacts.

So if you look at it this way, it becomes pretty easy to identify the mentally ill.  You target treatment settings, medications used for their treatment, and observed or stated symptoms of psychiatric symptoms.  We still will miss a few people, but if we can identify these folks, and keep guns out of their hands, I guarantee the rate of gun violence will go down.  It's a sure fire thing.  
(Of note: Satire alert)

Wednesday, January 14, 2015

The lovely wife on the psych ward

I have one thing to say about Mark Lukach's essay, "My lovely wife on the psych ward."  That one thing is: Read it!  It's beautiful.  Mr. Lukach does a masterful job of describing his feelings as he plows through two months' long episodes of psychosis with his wonderful wife. When a friend gives him a copy of R.D. Laing's The Divided Self: An Existential Study in Sanity and Madness, Mr. Lukach learns about the world of anti-psychiatry and psychiatric survivors.  He struggles through with wanting to be a good husband, to help his wife get better, but he questions whether what he is doing is right, and he stumbles through with his own guilt.  And when his wife gets better, they struggle with the bitter aftertaste of what it meant to be her caretaker, to be in control.  The story isn't all pretty, but the writing and the description of the conflicts is beautifully done.

Yet Laing ripped through a conception I had of myself that I held dear: that I was a good husband. Laing died in 1989, more than 20 years before I picked up his book, so who knows what he really would have thought. His ideas about mental health and its treatment could have shifted with the times. But in my admittedly sensitive state, I felt Laing saying: Patients are good. Doctors are bad. Family members botch things up by listening to physicians and becoming bumbling accomplices in the crime of psychiatry. And I was an accessory, conspiring to force Giulia to take medication against her will that made her distant, unhappy, and slow, and that silenced her psychotic thoughts. That same medication enabled Giulia to remain alive, so everything else was secondary, as far as I was concerned. I never doubted the rightness of my motives. From the beginning, I’d cast myself in the role of Giulia’s self-effacing caregiver—not a saint, but definitely a guy working on the side of good. Laing made me feel like I was her tormentor.