Wednesday, August 20, 2014

How Hard Is It To Find a Psychiatrist? Tell me your stories!



One of the concerns I have about funneling our resources into programs for involuntary treatment is that I believe it's difficult for those who want help to get it.  Some assume that those who don't recognize their need for help are society's sickest patients, and that resources should go to them first.  So I want to hear your stories of looking for a psychiatrist.

So let me ask you, how hard is to find a psychiatrist here in the United States?  If you found one easily --- say a morning's worth of phone calls and appointment within a reasonable time -- just say "Easy" and please tell me what part of the country you live in and if you live in an urban/suburban/rural area.  If you had a longer story, I'd love to hear that as well, with the same demographics.

Thanks so much!

Tuesday, August 19, 2014

Looking for People to Talk to Me about Involuntary Electroconvulsive Therapy (ECT or "shock" treatments)



As our regular readers may know, we are working on a book called Committed: The Battle Over Forced Psychiatric Care.  In Maryland, there is no provision for people to have ECT against their will, it's a voluntary procedure and someone else can't sign you up.  Before I learned about it from Shrink Rap readers, I didn't realize that there are other states where ECT can be court-ordered and done against a patient's will. 

I'm interested in talking to people about their experiences with involuntary ECT.  Anyone with a personal story is invited -- patients who've had it (court-ordered, not cases where people have been cajoled into voluntary treatment), but also family members, doctors, nurses, and the staff who do it, and even the judges who order it.  

I can be reached at email : shrinkrapblog at gmail dot com, by writing a comment on this post, or via Twitter @Shrinkrapdinah.  If you have no personal connection to forced ECT, please don't comment.  I do already know that many people think it's awful. 

Monday, August 18, 2014

What Happens When Patients Won't Take Meds?



You're here reading Shrink Rap, so you may think this is a post about patients who refuse to take psychiatric medications, and non-compliance with psychiatric medications gets to be it's own issue.  So it caught my attention when Dr. Albert Fuchs tweeted that he was interviewed by NPR about "What happens when patients won't take medicines."  Dr. Fuchs is a primary care doc with a concierge practice in Beverly Hills, so I wanted to hear what he had to say, and I invested 6 minutes of my life in listening to his NPR talk -- you may want to go to the website and listen as well.  He makes a good point about being cautious when an addictive medication is prescribe, and he notes that in Los Angeles people are pro-health, anti-medication and perhaps that skews who he sees, but that medication refusal is common.  I'm thinking that by the time you're paying an outrageous concierge fee to your primary care doc that either you're ill and  feel you need extra attention or money's not an issue in your life -- after all it's Beverly Hills.  But my other thought is why would someone invest in this type of care if they are not going to follow the doctor's suggestions?  If you're going to blow your doc off, do it when there's a $20 co-pay.  

That said, I'm not exactly the best of patients, and I've had a doctor who has wanted me to take calcium supplements for years.  She is insistent.  One look at me and one thing is clear: I'm well nourished.  I don't think I need supplements, I think I get plenty of everything in my diet, and a close friend started taking calcium on the advise of her doctor and promptly got a kidney stone, and the literature suggests that dietary calcium is better than supplements, at least for people in some demographics .  I assure my doctor that I ingest enough calcium. She's asked me what I eat, to which I've replied milk, yogurt, cheese, and ice cream.  "Do you eat ice cream everyday?"  Isn't that harassment?  Of course I don't eat ice cream every day, but I wish I did.  I surrendered, I bought a bottle of Tums and a few times a year, I eat one.  This way, when I see this doc, I can say with impunity that I sometimes take Tums and this seems to stop the conversation.  Maybe I'm wrong and someday I'll have brittle bones and wish I had listened and taken calcium supplements.  So I have mixed feelings about whether one always needs to follow doctors' orders exactly and under what circumstances.  Certainly the issue in psychiatry gets very complex if the patient is psychotic and  repeatedly decides not to take medications and keeps ending up in the hospital or puts himself or others at risk.  

 In the meantime, my favorite flavor, for anyone who wishes to buy me ice cream, is praline pecan. 


Tuesday, August 12, 2014

Suicide: A permanent answer to a temporary problem. Rest in peace, Robin Williams.



The news last night was tragic, Robin Williams has died of an apparent suicide of the early age of 63.  I saw the news and felt overwhelmingly sad.  Really?  He was a tremendous actor, a creative genius by any account, a man who I imagined had everything -- talent, wealth, fame, the wonderful ability to make people laugh and to brighten lives. Such people also get draped with love and admiration, though certainly at a price.   For what it's worth, Robin Williams has been open about the fact that he's struggled with both depression and addiction, but the complete story is never the one that gets told by the media.

Twitter started with 140 character links to Suicide Hotlines and suicide awareness, to statements about how depression is a treatable illness -- Is it always? -- and I hit re-tweet on a comment stating "We’re never going to get anywhere till we take seriously that depression is an illness, not a weakness" and several people retweeted my retweet.  I'm not sure why I did this; I don't think that most people still think of mood disorders as a "weakness," or that those who do might change their minds because of a tweet.  And I don't think that suicide does anything to reduce stigma.

One shrink friend tweeted a comment about how one should never ask someone why they are depressed, I guess because the "why?" implies something other than because biology dictated it, but if you've ever spoken to a person suffering from depression, you know that it comes in all shades of severity and that people often write a story to explain it.  Sometimes that story is right -- I'm depressed because of a break up, or because I don't have a job now, or because of on-going work stress -- and indeed, the person suffering often feels better after talking about the situation, after getting a new boyfriend or a new job, or after their boss moves to Zimbabwe.  I'm convinced that treatment works best when psychotherapy is combined with medication (if indicated) and while medicines are a miracle for some, they aren't for others.  As psychiatrists, we certainly see a good deal of treatment-resistant depression.  And yes, the anti-psychiatry faction may postulate that it is the treatment -- the medications, specifically - that cause people to kill themselves and others, but I will leave you with the idea that the science just doesn't support that.  Certainly, they aren't for everyone, but clinically I have seen medications do more good than harm in clinical practice overall. Please don't send comments about how treatment kills, I won't be publishing them. 

I know nothing about Robin Williams beyond what I've read in the media, and I know that the media presents it's own version of what happened.  I do imagine that Mr. Williams had the resources to get good care and that he may well have had treatment for depression since he was open about his struggle.  His story will be used to say "Get Help" and if you're feeling suicidal and aren't getting help, please do.  If you're feeling suicidal and "help" isn't making you feel better, please consider getting a second opinion or a different kind of help.  

The tragic thing about suicide is that it's a permanent answer to what is often a temporary problem.  People commit suicide for a variety of reasons -- unbearable psychic pain of the type that comes with Major Depression or Bipolar Disorder or any other psychiatric disorder, being just one reason.  Being in a bind (financial, love, legal) that one can't think of a way out of is another.  And tragically, on an impulse, with the barrier lowered by drugs or alcohol.  The truth is that when psychic pain --from depression or grief or heartbreak or anything else-- is bad, intoxication offers a quick relief for a fleeting moment, and when that moment of relief passes, a person's mood often drops violently and then suicide offers another way out, with the usual obstacles removed by the intoxicant.  If you're feeling sad, don't drink or use drugs to alleviate the pain, and if you must, don't do it alone and don't do it where there is easy access to a lethal means of ending your life.  

Sometimes, I imagine that there are people who have tried and tried to get help and that their pain remains so unbearable for so long that suicide offers them the only possible relief -- if such a thing is even to be had given that we don't what comes next and some religions will say that suicide leads to nowhere good.  Even if it provides relief to the person involved, it comes with the cost of leaving those who remain in horrible pain.  Sadly, depressed people sometimes imagine that the world will be better off without them, and often that idea is just not true. 

I hope that Robin Williams is in a better place, for his sake.  I hope that before he ended his life, he tried every possible treatment option, and that this wasn't an impulsive decision, or one based on an episodic relapse of either depression or substance abuse -- a relapse that may have resolved and let him live for decades more.  I hope his wife and children and all the people who knew and loved him will eventually find some peace.  His death, however, is not simply a personal one because he touched us all with his talent and his charisma.  What a tragic loss. 

Saturday, August 09, 2014

Is "Shrink" offensive? Take a one-question poll!


Over on Clinical Psychiatry News, we had a reader complain about our column title --Shrink Rap News.  He felt it was odd and offensive to use the term Shrink when people have worked so hard to reduce stigma.  I countered with the article there called "The Stigma of Being a Shrink" to discuss how we came to the title Shrink Rap for our work, and that the term "shrink" just didn't strike me as one which would alter care for our patients or leave us being seen in a negative light.  It's been 8 years of Shrink Rap -- the name has worked for us in the form of 3 blogs and a book, and well, shrink is one syllable while psychiatrist is 4 and psychiatrist does not lend itself to any cute puns or double meanings.  We're also not the only Shrink Rap or Shrink Wrap or Shrink Wrapped.  

So I thought I'd ask you: Is the term Shrink offensive?  Does using it alter the care our patients receive?  Should it be abolished from the jargon the way we no longer  use terms such as Lunatic?  Or the way we might like to get rid of words such as Crazy?  

I'm against stigmatizing people because of all sorts of things -- mental illness is only one of them.  I don't think anyone wants to be obese or have a drug or alcohol addiction, but some members of society seems to be okay stigmatizing those folks (--they could eat less and avoid their substances, apparently, if only they so chose...).  Calling a professional a 'shrink' -- I want to say "lighten up,"  but I'm all ears.  Not promising to change our blog name by any means, but what do you think?

And while we're talking about stigma -- there was a terrific article by Allen Frances over on the Huffington Post.  He notes, "Never has there been less stigma for having mild psychiatric problems, but never has there been more stigma for having severe ones." 


Wednesday, August 06, 2014

Sectioned -- on involuntary treatment in the U.K.


In America, people enter the hospital involuntarily in a process known as civil commitment.  On the other side of the pond, in Great Britain, it's known as being "sectioned."

My thanks to Mental Health @sectioned_ on Twitter who linked to this BBC radio program called "Shrink Wrapped" (not, not, not Shrink Rap) and a one-hour show on being Sectioned -- they interview a psychiatrist, a patient who has been sectioned roughly 10 times, and the police.  Here's the Link if you'd like to listen.  The issues sound to be the same on both sides of the Atlantic Ocean.  If you'd like to listen, it may only be available for a few more days.

Saturday, August 02, 2014

The Creative Brain : Links to Mental Illness?


If you're a psychiatrist, you likely know who Nancy Andreasen is.  For as long as I've been around, she's been one of those big names in psychiatry and someone who leaves you to wonder if she ever sleeps, or if she has a clone, because it's hard to imagine that one human being can accomplish so much.  She has a Ph.D in English literature, and she's a psychiatric researcher who studies schizophrenia, neuroimaging, genomics and schizophrenia, and she directs every organization she belongs to and has won more prizes than I care to mention. She's a former editor of The American Journal of Psychiatry, the Chair of the University of Iowa's department of psychiatry.  In addition, she writes books, and scuba dives.  And yes, she's married with children.  I've heard her speak, and I enjoyed her recent article in The Atlantic, "The Secrets of the Creative Brain" enough that I read it twice so I could share the highlights with Shrink Rap readers. 

First, Dr. Andreasen talks about Kurt Vonnegut -- his depression and his strong family history of mental illness.  You may recall that I reviewed his son's book on Shrink Rap, "Just like someone with mental illness only more so."  Vonnegut's mother committed suicide, other family members suffered from mental illness, but they are also a very creative family.  Andreasen notes:

For many of my subjects from that first study—all writers associated with the Iowa Writers’ Workshop—mental illness and creativity went hand in hand. This link is not surprising. The archetype of the mad genius dates back to at least classical times, when Aristotle noted, “Those who have been eminent in philosophy, politics, poetry, and the arts have all had tendencies toward melancholia.”

She mingles talk about the course of her work and her dual career (literature, then psychiatry) with a discussion of her interest in mental illness and creativity.  Andreasen goes on to talk about the work of Stanford research Lewis Terman who identified and followed people with notably high IQ's over time.  She writes:
  For example, they were generally physically superior to a comparison group—taller, healthier, more athletic. Myopia (no surprise) was the only physical deficit. They were also more socially mature and generally better adjusted. And these positive patterns persisted as the children grew into adulthood. They tended to have happy marriages and high salaries. So much for the concept of “early ripe and early rotten,” a common assumption when Terman was growing up.
 Andreasen notes that 'creative geniuses' are generally smart, but don't have to be all that smart.  She seems to indicate that an IQ of 120 will do.  She talks about how to measure creativity with a test -- and defines convergent and divergent thinking, but then notes that this may not really be a way to measure creative genius.  Instead she settles on the Duck Test, and here at Shrink Rap, we like all things ducky, so I'll quote her on this one: 
A second approach to defining creativity is the “duck test”: if it walks like a duck and quacks like a duck, it must be a duck. This approach usually involves selecting a group of people—writers, visual artists, musicians, inventors, business innovators, scientists—who have been recognized for some kind of creative achievement, usually through the awarding of major prizes (the Nobel, the Pulitzer, and so forth). Because this approach focuses on people whose widely recognized creativity sets them apart from the general population, it is sometimes referred to as the study of “big C.” The problem with this approach is its inherent subjectivity. What does it mean, for example, to have “created” something? Can creativity in the arts be equated with creativity in the sciences or in business, or should such groups be studied separately? For that matter, should science or business innovation be considered creative at all?
Andreasen began to study people from the Iowa writer's workshop and people she deemed to be creative geniuses.  At first, she hypothesized that they would have more relatives with schizophrenia than the average person and she based this on her observation that some geniuses (e.g. Einstein) had relatives with schizophrenia.  
As I began interviewing my subjects, I soon realized that I would not be confirming my schizophrenia hypothesis. If I had paid more attention to Sylvia Plath and Robert Lowell, who both suffered from what we today call mood disorder, and less to James Joyce and Bertrand Russell, I might have foreseen this. One after another, my writer subjects came to my office and spent three or four hours pouring out the stories of their struggles with mood disorder—mostly depression, but occasionally bipolar disorder. A full 80 percent of them had had some kind of mood disturbance at some time in their lives, compared with just 30 percent of the control group—only slightly less than an age-matched group in the general population. (At first I had been surprised that nearly all the writers I approached would so eagerly agree to participate in a study with a young and unknown assistant professor—but I quickly came to understand why they were so interested in talking to a psychiatrist.) The Vonneguts turned out to be representative of the writers’ families, in which both mood disorder and creativity were overrepresented—as with the Vonneguts, some of the creative relatives were writers, but others were dancers, visual artists, chemists, architects, or mathematicians. This is consistent with what some other studies have found.
Andreasen became interested in using MRI to study the brain structure of people with schizophrenia (she is a pioneer in this field).  She began to wonder what imagining studies might reveal about the brains of the very creative.  
Designing neuroimaging studies, however, is exceedingly tricky. Capturing human mental processes can be like capturing quicksilver. The brain has as many neurons as there are stars in the Milky Way, each connected to other neurons by billions of spines, which contain synapses that change continuously depending on what the neurons have recently learned. Capturing brain activity using imaging technology inevitably leads to oversimplifications, as sometimes evidenced by news reports that an investigator has found the location of something—love, guilt, decision making—in a single region of the brain.
And what are we even looking for when we search for evidence of “creativity” in the brain? Although we have a definition of creativity that many people accept—the ability to produce something that is novel or original and useful or adaptive—achieving that “something” is part of a complex process, one often depicted as an “aha” or “eureka” experience.
She then goes on to talk about using PET scans to look at the workings of the brain when people are asked to think about specific "episodic" events versus free-associating or REST (random episodic silent thought).
Based on my interviews with the creative subjects in my workshop study, and from additional conversations with artists, I knew that such unconscious processes are an important component of creativity....In my own version of a eureka moment, the answer finally came to me: creative people are better at recognizing relationships, making associations and connections, and seeing things in an original way—seeing things that others cannot see. To test this capacity, I needed to study the regions of the brain that go crazy when you let your thoughts wander.
Her subjects spend 3 days in Iowa.  During this time, Dr. Andreasen has them to dinner at her house, drives them around her 40 acre nature retreat, then she interviews them (in-depth inquiries about their childhood, interests, families and more) and she scans their brains.  It sounds like fun.  I don't know if the control group gets dinner and the estate tour or not, but I'll assume so. She's studied 13 creative people and 13 controls.  Of the 13 creative types, 2 had parents who died of suicide (an exceedingly high number).
The creative subjects and their relatives have a higher rate of mental illness than the controls and their relatives do (though not as high a rate as I found in the first study), with the frequency being fairly even across the artists and the scientists. The most-common diagnoses include bipolar disorder, depression, anxiety or panic disorder, and alcoholism. I’ve also found some evidence supporting my early hypothesis that exceptionally creative people are more likely than control subjects to have one or more first-degree relatives with schizophrenia.
 Andreasen speculates about why the creative geniuses may have a higher incidence of mental illness:

One possible contributory factor is a personality style shared by many of my creative subjects. These subjects are adventuresome and exploratory. They take risks. Particularly in science, the best work tends to occur in new frontiers. (As a popular saying among scientists goes: “When you work at the cutting edge, you are likely to bleed.”) They have to confront doubt and rejection. And yet they have to persist in spite of that, because they believe strongly in the value of what they do. This can lead to psychic pain, which may manifest itself as depression or anxiety, or lead people to attempt to reduce their discomfort by turning to pain relievers such as alcohol.
Her subjects talk about the joy they get from creating, and she notes that they work much harder than other people, because they love their work.   Finally, in linking creative genius to mental illness, Andreasen ends with a mind-boggling thought:
Some people see things others cannot, and they are right, and we call them creative geniuses. Some people see things others cannot, and they are wrong, and we call them mentally ill.
 


   

Saturday, July 26, 2014

Of Guns and Ducks



Around the web, I thought I'd point out some interesting stories:


A federal court upheld the legality of a Florida law which forbids doctors to discuss gun ownership with patients. The law, passed in 2011, was challenged as being a violation of a doctor's right to free speech.  Apparently, the second amendment is more important than the first amendment.  Why stop at gun ownership, perhaps every aspect of medical care should be legislated?  What right does my doctor have to pester me about whether I smoke or how much I drink or whether or not I'm getting enough calcium?  From the StarTribune:
The ruling by the 11th U.S. Circuit Court of Appeals in Atlanta overturned a previous decision that had declared the law unconstitutional. An injunction blocking enforcement of the law is still in effect, however.
The 2011 law, which had become popularly known as "Docs vs. Glocks," was challenged by organizations representing 11,000 state health providers, including the Florida chapters of the American Academy of Pediatrics and the American Academy of Family Physicians
Doctors who break the law could potentially be fined and lose their licenses.

The issue of boundaries in psychiatry is always a sticky one, and there are times when it seems prudent to bend some of the usual boundaries by a bit.  Still, I tell students, readers, anyone who asks me, that the two rules one should never violate: Don't sleep with or kill you patients.  Hmmm, this is a tragic story, but as the media is reporting it, a psychiatrist in a Philadelphia suburb pulled out his own gun and fired on a patient who had already shot at him and had killed his case manager.  Read the NY Times account Here.  The details are still unwinding.

And on to ducks:

Iraq veteran Darin Welker, pictured above, suffers from pain, depression, and post-traumatic stress, and he has found comfort from his 14 emotional support ducks.  Farm animals, however, are not legal in his Ohio town, and there is a hearing to force Welker to get rid of the ducks!  We at Shrink Rap say NO!  Let the vet keep his support ducks! So long as he does so in a way that does not disturb others or does not endanger the ducks, we're on his side.  And apparently the same town allows one therapy pot-belly pig per family, so why not some ducks?  Link to the article is Here and there is a video of Welker with his ducks.

Finally, over on Clinical Psychiatry News, I responded to a reader's comment that the term "shrink" is odd and offensive.  After eight plus years, I think we're moving on as the Shrink Rappers, though I am sorry it offends someone.  What do you think?  Read:  The Stigma of Being a Shrink.

I'm going to try allowing comments again. I miss everyone's input, but I will be moderating for now.




Wednesday, July 23, 2014

Stanley Family Foundation gives $650 million for Psychiatric Research



From the New York Times, In Spark for a Stagnant Search, Carl Zimmer and Benedict Carey write:

Late on Monday, the Broad Institute, a biomedical research center, announced a $650 million donation for psychiatric research from the Stanley Family Foundation — one of the largest private gifts ever for scientific research.

It comes at a time when basic research into mental illness is sputtering, and many drug makers have all but abandoned the search for new treatments.

Despite decades of costly research, experts have learned virtually nothing about the causes of psychiatric disorders and have developed no truly novel drug treatments in more than a quarter century.

Broad Institute officials hope that Mr. Stanley’s donation will change that, and they timed their announcement to coincide with the publication of the largest analysis to date on the genetics of schizophrenia.

Let me also encourage you to listen to the podcast linked to this article.


 

Sunday, July 20, 2014

Does Anti-psychotic Withdrawal Make People Kill?



So here's an interesting article in the Irish Times: Niamh O'Donoghue writes in "Murderer accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court."  I'll let you surf over there if you want to read more, the title says enough for me.

My first thought was :  Really?  People stop their medications all the time, cold turkey, without doctor supervision or approval, and they don't generally kill people.  So how do you know if someone's "symptoms" --like agitation -- are he result of medication withdrawal, or the result of a recurrence of the original illness that the medication was treating?  There's not a great way to sort that one out, but I was befuddled by the idea that one would attribute murder to medication withdrawal.  Maybe that should be on the TV commercials with the list of side effects, "Stopping this medication suddenly can lead you to kill people." 

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at: http://www.independent.ie/irish-news/courts/murder-accused-was-unable-to-refrain-from-killing-the-deceased-because-of-medication-withdrawal-psychiatrist-tells-court-30437572.html#sthash.6SAmLiC6.dpuf

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at: http://www.independent.ie/irish-news/courts/murder-accused-was-unable-to-refrain-from-killing-the-deceased-because-of-medication-withdrawal-psychiatrist-tells-court-30437572.html#sthash.6SAmLiC6.dpuf

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at: http://www.independent.ie/irish-news/courts/murder-accused-was-unable-to-refrain-from-killing-the-deceased-because-of-medication-withdrawal-psychiatrist-tells-court-30437572.html#sthash.6SAmLiC6.dpuf

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at: http://www.independent.ie/irish-news/courts/murder-accused-was-unable-to-refrain-from-killing-the-deceased-because-of-medication-withdrawal-psychiatrist-tells-court-30437572.html#sthash.6SAmLiC6.dpuf

Wednesday, July 09, 2014

Shrink Notes: what does your doc think of you?



I've written before about shrink notes back in 2011.  See Here and Here.
With the increasing transparency we're seeing with electronic records, there are now systems that allow patients to access their doctor's notes.  The first time one of my patients did this, he casually mentioned that the record included the wrong dose of a medication, and I suggested my patient might want to tell his doctor about this.  

In psychiatry, we've been a bit touchy about this.  Patients might be distressed to see what we write about them, they may see some of the terms we use to describe them (like delusional?) as being negative.  

The New York Times has an article discussing a pilot study in Boston to give patients electronic access to their therapists' notes.  In What the therapist thinks of you, Jan Hoffman writes: 

The pilot project has raised questions in the mental health community. Which patients will benefit and which might be harmed? How will the notes alter a therapeutic relationship built on face-to-face exchanges? What will be the impact on confidentiality and privacy?
And the project presents difficult choices for those who argue for parity between medical and mental health patients. Should patients with schizophrenia, for example, who may stop taking their medication after reading that they are doing well, have the same access to treatment notes as those with irritable bowel syndrome?
But the lingering underlying question is, do patients really want to know what their therapists think? Dr. Kenneth Duckworth, who is the medical director of the National Alliance on Mental Illness, an advocacy group, said: “I’ve offered to share my notes with patients and they’ll say, ‘No, I’m good.’ But it’s a good concept that should be researched.”

The article goes on to describe the content of some therapist's notes and the impact it has on patients to read it:

He clicked open another therapy note.
Mr. Baldwin “is continuing to try to push himself to get out more and to be more socially connected even while his emotions tell him to do the opposite,” Mr. O’Neill wrote, adding that his patient is “clearly making good, and even courageous, efforts on a number of fronts.”
Mr. Baldwin, who celebrated his birthday recently with a museum lecture, movie and dinner, flushed with pride.

Hmm, I thought.  These are the type of interpretations I made aloud to the patients, they aren't the stuff of my notes, and if they were, I'd be living in the office trying to write accurate process notes of sessions.  A lot goes on in a session, and notes of this type could be very long.  I'd be hard pressed to feel I could prove that someone's emotions were telling them not to be socially connected and to stay inside -- what does that even mean?  Oh, truth be told, I write really boring notes.  In 20+ years no patient has ever asked to read their notes, and if they did, they'd find it a really boring read.

I'd love you're input, but comments are still off while the blog settles down. 


  

Sunday, July 06, 2014

Guest blogger Dr. Sana Johnson-Quijada on Freedom and Self Care

I met Dr. Sana Johnson-Quijada at the APA Annual Meeting this year in New York.   Sana has her own blog Friend to Yourself, and I invited her to do a guest blog on Shrink Rap.  In honor of Independence Day, she sent the following post. 

Self-Care is Freedom, is Democracy, is Because We Are Accountable

Self-Care Tip #159 – Be accountable for and to yourself.
It was about 100 degrees Fahrenheit, which in my part of the world is considered hot.  But in Washington D.C., I considered that temperature general anesthesia.  I was breathing it in and trying hard to remain alert.  Just when I thought I could hold out no longer, I saw him.  Big and expressive, the long form of Abraham Lincoln was there, surrounded by loud irreverent people.  My brother and I were wiping sweat out of our eyes trying to keep track of our kids.  We wanted to read the Gettysburg Address for our kids, and found ourselves screaming.  The kids could barely hear the words above the disinterested rabble around us.  Despite all this, I was choking; a weepy, sweaty, nearly anesthetized but free American.
Four score and seven years ago our fathers brought forth on this continent a new nation, conceived in liberty, and dedicated to the proposition that all men are created equal.
Now we are engaged in a great civil war, testing whether that nation, or any nation, so conceived and so dedicated, can long endure. We are met on a great battle-field of that war. We have come to dedicate a portion of that field, as a final resting place for those who here gave their lives that that nation might live. It is altogether fitting and proper that we should do this.
Just down the corner from Lincoln is a president’s list of sites to see, informers and reminders of who we are and where we came from.  However, none of them were “my Lincoln” experience.
But, in a larger sense, we can not dedicate, we can not consecrate, we can not hallow this ground. The brave men, living and dead, who struggled here, have consecrated it, far above our poor power to add or detract. The world will little note, nor long remember what we say here, but it can never forget what they did here. It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us—that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion…
A couple of days ago, writing the post about how stress intersects with medicine, I remembered “my Lincoln.”  It may seem like a stretch at first but take a minute.  Self-care is a way of saying, “I am free.”   In places where life is cheap, almost without value, self-care is not much of an option.  It is because of freedom that we can extricate the meddling fingers, the invasions, and be the keeper of our own private spaces however we choose to.  It is because of freedom that we can tell people that although my brain is ill and although I take medication, I am equal. Saying that is self-care.  Saying that is possible if we take that freedom to keep our own accountability for our own selves.  Accountability is not the same as blame.  Having accountability for our freedom is not the same as being at fault for what came before freedom, nor our current conditions.
—that we here highly resolve that these dead shall not have died in vain—that this nation, under God, shall have a new birth of freedom—and that government of the people, by the people, for the people, shall not perish from the earth.
If you’re not accountable to your inner self, if you’re only accountable to your actions, or you’re only accountable to what others determine and define about you, than you are not free.  You are blamed.
Accountability is such a tender privilege.  We might lose it if we forget who we are, where we came from and our rights to freedom.  Democracy is self-care.
Question:  How do you see the relationship between self-care and your freedoms? 
I practice psychiatry and parent, with my husband, our 3 small children.
Woven into this, writing and connection to community continues to bless me.  I am grateful. 

Friday, June 20, 2014

Tired. Just Tired.



For years, I've absolutely loved having  Shrink Rap.  I've loved having a place to write, to vent, to share something cool I've learned, and I've learned so very much from readers who have really changed my life.  What a great experience from a thought at the kitchen table that started, "I want a blog.  What's a blog?"  Shrink Rap has inspired me to keep current with psychiatry and to learn about things to write about that I might otherwise just skip.  I love having a place to ask questions, especially when they're about things that make my brain start doing somersaults (--well, not really, I think it's anchored in there okay).   Someplace to talk about things that are really bothering me or to share a funny cartoon or to just be a bit ducky.  

Sometimes, over the years, I've gotten really annoyed.  As much as I like hearing about others peoples' experiences, I don't like when people generalize their interior world to everyone else. And when it's an incessant, it gets wearing.

Lately,  I'm totally consumed with writing our next book.  I'm meeting the most interesting of people, and it's fine with me that some of them are very much in favor of involuntary psychiatric care, for what seem to be caring and reasonable agendas, and some of them are very much against involuntary psychiatric care, for what seem to be caring and reasonable agendas.  But my brain is consumed with this.

And as much as I've loved Shrink Rap, the drum beat of negative comments and the inter-reader bickering, well, it's tiring.  For a short while, I moderated comments.  That's work, one more thing to do when I should probably be making pesto instead. Roy got tired long ago, and Clink chimes in when something really inspires her, so I've been most of the noise for a long time now.

I'm tired.  Just tired.   We'll see. I think I'm taking a little rest for now.

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?

Saturday, June 07, 2014

In the Works, "Committed: The Battle Over Forced Psychiatric Care."



Good morning, I've missed you.  Blogging has not been the same lately and I've let some great topics go by. 

 Let me tell you what I've been up to.

There have been so many things to write about lately, and I will tell you that my brain is just bursting with all the work Clink and I are doing on our new book: Committed: The Battle Over Forced Psychiatric Care.  ClinkShrink is doing some of the background stuff, she's being (as always) the forensic expert, she's sweeping up after my grammatical carelessness, and correcting the forensically idiotic things I say.  She's focusing on legal cases and a chapter on restraint and seclusion.  I'm taking the lead on writing some of the other chapters, and her description of this is that it's like trying to keep up with a hamster in an exercise wheel.  That hamster would be me, and I'm having no more luck keeping up with my own thoughts then Clink is, but every now and again, I jump off and take stock.  I started with this very funny idea that I would work on one chapter at a time, and that each chapter might take a month.  Okay, so some chapters are taking a very long time to get the parties lined up for, and I'm working on 5-7 chapters at once.  These days, I'm as much journalist as shrink.

Would you like to hear about the book?  Don't hold your breath on being able to read it anytime soon, but it's making progress and some days the progress is much faster than I expected.

The first two chapters are from the perspectives of patients -- wonderful, intelligent, articulate, people -- one of whom found that involuntary hospitalization was traumatizing to her and left feeling her injured, another  of whom found it help keep her life from disintegrating.  I purposely chose people who had good insight and believable stories -- I didn't want the person who felt her care was unkind to be dismissed; I thought her complaints were valid and warranted a critical look.  Both patients allowed me to access their medical records, and to interview their doctors and family members, so I felt like I got a good sense of what went on.

Since the book is "The Battle Over Forced Psychiatric Care,"  the third chapter is called The Battleground.  This is the most difficult chapter to write to date, just because it's taking time to get together with everyone.  So far, I've interviewed  E. Fuller Torrey of the Treatment Advocacy Center, Ron Honberg of National NAMI, Ira Burnim of The David L. Bazelon Center for Mental Health Law, and an anonymous gentleman from the Church of Scientology in New York City.  I have times set up later this month with Paul Summergrad, the President of the American Psychiatric Association, and Daniel Fisher of the National Empowerment Center (a Recovery Group), and I have been working hard with MindFreedom (a survivor organization) to find a time for a conference call.  Some other great people have chimed in as well: Xavier Amador, Solomon Snyder, and Paul Appelbaum has been helpful every step of the way.  

Chapter 4 is currently on Civil Rights, and it's taken from a news story our readers pointed me to about a woman in Vermont who was held in a hospital for 5 and a half weeks with no hearing.  The case is the springboard for discussion, so I've talked with a wonderful legal aide attorney in Vermont as well as the president of the Vermont Psychiatric Society.  As in many of our chapters, the laws there are changing as we write and the hamster keeps trying to run faster.

Chapter 5 is on law enforcement and how people enter the mental health system through police interventions.  I focused here on Crisis Intervention Teams, and Officer Scott Davis has been a gem to let me ride along with him and share his world with me, and Judge Steve Leifman in Florida has given some wonderful insights and statistics.

Chapter 6 is on the inpatient unit, and the chairman of psychiatry, Dr. Ray DePaulo was truly my hero for allowing me to shadow him on the unit.  Steve Sharfstein, a former APA president and CEO of Sheppard Pratt Hospital talked with me about how his institution works, Dr. Bruce Hershfield a former a superintendent of Springfield State Hospital, shared his insights with me, and I had a present-day tour of the state hospital, which now houses 230 people, down from a high over 3,000. 

In short, lots of lunches, and lots of insights from really brilliant people.  

Clink is working on Chapter 6: restraint and seclusion, and the plan down the line is to look at the legal system through the public defender's office,  outpatient commitment, violence and mental illness, guns and mental illness, maybe forced ECT, maybe indefinite confinement of sex offenders (we'll see), and a little more focus on both families and legislation.  Jeff Swanson at Duke has provided invaluable guidance, and I've grown very fond of these folks at Penn from The Scattergood Program for the Applied Ethics of Behavioral Healthcare -- and I'm looking forward to spending more time with Candice Player, and John Monahan, once I finish the current chapters and more forward.  For my brief blog post, there are many many people missing, but I wanted to give some quick shout outs and just an update on the quite nature of Shrink Rap these days.

What do you think?  Obviously our blog readers have been instrumental in shaping in our writing.  But if you're looking for a book to either extoll the virtues of forced care or to completely vilify it, you may need to hold back.  These are complicated issues and our goal is to talk a close look at involuntary treatment, figure out when it can be made kinder and gentler, and figure out if or where it fits in with psychiatry and/or the prevention of violence.