Shrink Rap

Don't Smile (...at least not on Facebook)

2009-11-23T21:54:00.002-05:00

A Canadian woman lost her disability benefits because her insurer found her smiling, and vacationing, face up on her Facebook page. See details Here.

The article notes:

"In the moment I'm happy, but before and after I have the same problems" as before, she said.

B--- said that on her doctor's advice, she tried to have fun, including nights out at her local bar with friends and short getaways to sun destinations, as a way to forget her problems.

She also doesn’t understand how Manulife accessed her photos because her Facebook profile is locked and only people she approves can look at what she posts.

It kind of reminds me of Roy's post: Wipe that smile off your face. Thanks to Meg for the link!

Shrink Rap Barbecue

2009-11-22T22:04:00.003-05:00

The three Shrink Rappers and their friends got together tonight for a Korean barbecue. I volunteered to write the blog post for it. After I spilled dipping sauce on my jeans I figured that was the best way to ensure the incident would be reported most accurately. It was purely an accident and their was no alcohol involved. I did spend the remainder of the evening smelling "nasty, putrid and fishy" in the words of one diner, even after a thorough cleansing in the restaurant bathroom. (I'm much more coordinated climbing than doing anything else, including walking.)

Nevertheless, the company was wonderful and we enjoyed talking about our plans for the blog, the book and our Twitter feeds. I did manage to edit one of our recorded podcasts and I'm just waiting for Roy to give me our theme song and directions for how to put it up on iTunes and the My Three Shrinks web site. Besides that we talked about emotional support dogs on planes, impaired (but not smelly) physicians, licensing laws and hummus. We seem to be fixated on hummus these days.

Roy and I talked about the iPhone apps we'd like to design someday. Dinah showed us her new phone, a lovely shade of green.

We need to do this more often.

Hummus Links.

2009-11-22T00:22:00.006-05:00

Rach got me worried about rancid tahini. I asked Victor, he says it can stay in the fridge for six months. I checked Chowhound and here is what I found:

How Long For Tahini?

I also found a Chowhound site with tips for making homemade hummus:

Why is restaurant hummus better?

Happy dipping?

Getting Help When Money is Tight and When It's Not

2009-11-21T17:15:00.005-05:00

Moving on from the Hummus debate...

Today's NYTimes has an article called Getting Mental Health Care When Money is Tight.
Leslie Alderman writes:

According to a recent survey by the federal Substance Abuse and Mental Health Services Administration (Samhsa, pronounced SAM-suh) , the leading reason that people with mental health issues don’t seek treatment is cost. They fear the fees.

The article goes on to list websites, support groups, self-help ideas (yes, exercise was in there!), pastoral counselors and an assortment of options for people who want help but are uncomfortable with the cost. The author even suggests:

If you have a good relationship with your primary care physician, you could see him or her. Your doctor may be able to refer you to a local mental health center for therapy, and maybe consider medication to help you out of your immediate funk. Doctors may also know of psychologists who see patients on a sliding fee scale.

Hmmm, sounds like psychiatrists aren't a very generous crew-- there's no mention of the idea that one of those might discount their fees.

In Maryland, there have traditionally been a few options:
1) Community Mental Health Centers have treated uninsured, indigent patients, specifically those with major mental illnesses. These patients are deemed "gray zone" and have been cared for in the clinics....not sure that continues with all the governmental budget cuts. Often these patients end up being eligible for Medicaid, and sometimes SSDI (Social Security Disability) and eventually Medicare.
2) Homeless patients (and homeless is defined pretty loosely, and not limited to 'street' people--) can be seen at Health Care for the Homeless-- they're sliding fee scale allows for
very low fees.
3) The Pro Bono Counseling Project coordinates care for those with limited resources through a network of volunteers in the community. The list includes therapist of every ilk-- but I will say the social worker volunteers greatly outnumbers the psychiatrists.
4) Teaching programs (and this was an option in the NYTimes article) offer treatments of all types--- including psychoanalytic training programs where discounted analysis is available.

Do you know of other resources? By all means, write in!

So my other thought was this. I think health insurance is a good thing, and actually, I hope some reasonable level of health care should be accessible to all, but given that it's not, have we become complacent in a way that's not helpful? The article starts out talking about a person with what may be a major depression and the person is afraid that the cost of treatment will add to the stress:

IMAGINE this situation. You fall into a deep malaise. Friends say you need help, but you don’t have insurance (or the insurance you do have has very limited mental health benefits), and you worry that extra bills will only add to your malaise. So you do nothing.

The article goes on to describe discount means of getting care, and you know I think these are all reasonable options. But we all know there are people who worry about money with a variety of thresholds-- one could worry that extra bills will add to the stress even if there's money in the bank. And no where does the article suggest that if there is some means of paying for care, that the cost of NOT getting treatment may well exceed the cost of getting care. Maybe the person above has a depressive episode-- maybe he'll go for an evaluation, a few weekly visits, then a year's worth of monthly visits, and get meds from Walmart or free doc samples. Let's pretend he responds well to the first medication, that he gets a lot out of a few therapy sessions, and ...hmm....maybe $600 later he feels a lot better. Let's say he doesn't spend that money and he's miserable. Let's say he loses his job, he loses opportunities...he lives life less fully.

I've watched people who pay $20K year for their child's kindergarten not be willing to go outside their HMO to get appropriate medical care for the same child.

I liked Alderman's article, she offers good suggestions. I guess I just wished that she'd made the suggestion that, if possible, psychiatric treatment might be worth paying for. I know I'm going to get comments from people who really do stretch to pay for their treatment. I'd love to hear from the folks who have a few resources but still elect not to get treatment they might like to have.

In The Hood

2009-11-20T20:46:00.000-05:00

One of my Twitter followers recently asked me to blog about what's been happening in the prison neighborhood recently. Basically what's happening is that there is a serial rapist running around central Baltimore. This past week a woman's body was found three blocks from the prison. The police suspect the killing took place during a sexual assault, and they sent police cadets out to scour the public housing complex nearby to look for evidence. (I have to admit, when I saw them my first thought was: "Oh, they'll find lots of evidence. Some of it may even be related to the killing!") Today the local newspaper said that DNA evidence has revealed that the rapes are being committed by two different suspects. One suspect is targeting women who are waiting at bus stops while the other is committing home invasions.

So why am I blogging about this? (I mean, other than because somebody asked me to.) Because periodically somebody asks me if I feel safe working in prison. Well....compared to the streets of Baltimore....need I say more?

What Should I Do?

2009-11-19T22:54:00.005-05:00

A reader asks if we give advice. I hope it's okay if I copy and paste the question from the comment section of another post, I'll leave the commenter's handle out:

I went to a psychologist 7 or 8 years ago and all she did was tell me what I should do. “Go there, do this, etc.” She didn’t listen to me at all. If she had, she would have known that the things she was telling me to do were things that I would never ever do. I quit after 2 or 3 sessions. I decided to try therapy again about a year and a half ago and my psychiatrist is the complete opposite. She has never given me a single word of advice and even when I directly ask her opinion, she will only occasionally give me a straight answer. I appreciate the fact that she isn’t trying to force off-the-wall ideas on me, but sometimes I wish she’d put in her 2 cents. Where do you guys stand on this? I’m just curious as to what’s the “norm” since my 2 experiences have been so drastically different. Thanks.

Traditionally psychotherapists don't give advice--- perhaps this differentiates "therapy" from "counseling" which does imply that one person knows what's best. Psychodynamic psychotherapy is about delving and understanding unconscious conflicts, and it's done by looking at the process of the material a patient brings to the session. Rather than go for the superficial and concrete, perhaps there is something to be gained in understanding why a patient wants the therapist to give them advice. It's about understanding the mechanisms that guide the patient, not the specifics.

So I'm not an analyst, I'm particularly quiet, I tend to say what I think, and I'm a physician who treats conditions that I believe have some biological input. To some extent, I have to give advice: Take this medicine at this time. Don't take that medicine with this one, it'll kill you. Don't drink alcohol when you're taking Xanax, that'll kill you, too. I believe that when someone is suffering from a problem in a way that up-ends them, they should make it their job to do what they have to get well. What helps depression: medicine, exercise, sleeping enough, not sleeping too much, structure, being empowered. There was a study recently that suggested a link between Mediterranean diets and lower rates of depression--- so I tell people to eat hummus (if they like it!). I even suggest a brand because I've personally taste tested them all and have a strong preference. (Is it awful to admit this?)
Do I give advice otherwise? Yeah, sure. Sometimes I tell people who need more structure that they should get a dog. Dogs are good--- ya gotta get up and walk them, they're interactive, they're entertaining, you have to feed them, they pull people outside of themselves just a little, and they are object of passion-- passion, I think, is good.

What have I discovered? People come to their appointments, mostly. They take their medicines, mostly. No one really does much more of what I suggest. No one has bought a dog because I've told them to. And people who don't want to exercise rarely do so because a psychiatrist tells them the research says this will help. I'll let you know how it goes with the hummus. I don't think Freud would have liked me.

So I tell my patients what to do sometimes. The more salient question would be: Do you tell Roy what to do?

Do the Kids Do it Differently?

2009-11-17T19:42:00.006-05:00

We've been talking about stigma and whether someone should tell people they suffer from a mental illness. I've said that some people advertise their illnesses and it draws people in, while other do it and find they are shunned. Commenters have had a variety of responses, but most votes go against telling people one has a mental disorder.

Does it matter what you have? Or how much it's disabled you? Or how it's framed? I talked about the chemistry teacher on antidepressants (and yes, the demographics were changed)--- she framed it as she was having a hard time after a major loss, not that she was suffering from a major mental illness that might effect her current behavior or reliability.

So is it different for the kids? They've grown up on Cymbalta, Zoloft, and Viagra commercials. They've posted their lives on MySpace and Facebook. When I think about my kids' friends, I have to say they are all pretty open about psychiatric illnesses-- I've had kids spend the night who take psychiatric meds, I've had little peeps point out a window and say, "That's where my psychiatrist is." I've heard that Sal and Hal both see the same therapist, that Bobby's been in treatment for anger issues, that Tom, Dick, and Harry are all on ADD meds. I've had a physician tell me about his depression and his family's therapy while we watched our kids' compete (and the whole teams' parents listened on). Back in the day when big pharma distributed pens, my kids would take them to school and other kids would volunteer, Hey I take that! When I think about it, I know a lot of kids who've had a lot of treatment.

ugh...blogger won't let me add a pic...

To Tell or Not to Tell? That is the Question.

2009-11-16T17:46:00.003-05:00

Should patients with psychiatric disorders discuss them openly? Is it better to let it be known like it's no big deal, or to hold on tight to those secrets? We've talked about this a lot when we've talked about the meaning, the stigma, and the consequences of psychiatric labels. It seems to me that some people advertise their problems and are no more worse for the wear: they start talking at a party about how they have bipolar disorder and suddenly they are the magnet for everyone else's bipolar stories. It's refreshing, in a way, how free they feel to be open. Perhaps some of it is career-dependent: certainly it's more permissible among artists and musicians to have suffered, and some problems with mood or substances can be so much a part of landscape as to defy stigma.

Why now am I bringing this up? Carpool today: "We talked about therapy and antidepressants in chemistry." Hmmm, that's not chemistry, shouldn't they be balancing acid-base problems? "And what does your teacher have to say about it?" Apparently the teacher was on antidepressants for years during a difficult time, but she suggested the whole class probably had issues and things to talk about in therapy. Why not?

What do I think? This is a young, well-loved and respected teacher. If she's comfortable telling the kids that treatment has helped her, more power to her. Maybe someday some troubled person will figure Ms. Chemistry was cool with it and will get help. As long as they get to the acid-base stuff eventually.

Life Without Parole, But With Health Care

2009-11-15T09:13:00.000-05:00

The rising cost of prison health care is due mainly to the aging inmate population according to an article I saw on CNN recently. To me this really wasn't news; is it any surprise that older people have more medical problems? Or that the prison population as a whole is older due to longer sentences? Not really.

This story interested me because the Supreme Court is now considering the issue of life without parole for juveniles. The idea is that juveniles can be rehabilitated and should be given a second chance, eventually.

I can't help wondering if this issue is coming up now in part because prison officials, and inmate advocacy organizations, are starting to realize the full cost of a system filled with "lifers". They need more than just medical care. They need physical accomodation (and security accomodation) for wheelchairs, quad canes, braces, pumps and other medical devicies. They need nursing care for feeding, dressing and bathing. They need psychiatric care for dementia and other age-related psychiatric problems. Eventually, they need hospice care.

Medical parole, also sometimes called "compassionate parole", is available in some systems. But this is sometimes dependent upon a terminal illness with a six month life expectancy. And it's not always granted if the inmate's offense was particularly notorious or horrific.

It's good to periodically examine our sentencing policies, but I get wary of any mandatory sentence that's based on a class of offenders rather than on the offense itself. Singling out people with mental disorders, juveniles, the developmentally disabled (and yes, women automatically get classified as 'vulnerable' and less culpable too) makes me uncomfortable. Banning life without parole for a juvenile, simply because he is a juvenile, negates a host of sentencing factors that a judge should be allowed to consider. These cases are challenging and difficult, and sentencing decisions are best left to an experienced judge who has access to all the information in a given case.

If life without parole is banned for juveniles, the next step logically would be to reconsider long sentences for older inmates. Should someone who is fifty years old be given a 30 year sentence? Given that the average life expectancy for an American is 77 years, that's an automatic life sentence. What about someone with cancer or HIV, someone with a potentially fatal illness who is not immediately dying? Should we base a sentence on five year survival rates? Otherwise, we are giving a life sentence, without parole. If you ban mandatory life for juveniles, you need to reconsider sentences that are the functional equivalent to mandatory life.

It gets complicated but hopefully these are the issues that the Supremes are going to be thinking about.

FDA & Social Media Hearing: #FDASM Word Cloud

2009-11-13T21:00:00.001-05:00

Twitter was awash with thousands of tweets (click link to left to read them) the past few days regarding the FDA's hearing today and yesterday about regulation of pharmaceutical marketing on the internet and using social media. Above is the word cloud for the tweetstream on the topic (minus all the references to fdasm, fda, RT, bit.ly, http, etc).

If you want to dive deeper, check out the links on tr.im/hitlinks and on fdasm.com. A list of links to many of the presentations are available here. Public comments to the FDA are being accepted through Feb 28, so go to one of the above links to find the public comments page if you have something to say about this area. The controversies involve things like providing fair balance in 140 characters, making it easier to find plain English info on adverse effects, and whether the FDA rules about drug companies hunting down every mention of adverse effects should be revised based on the preponderance of user-generated content out there.

Shrink Rap: Grand Rounds is up at CRZEGRL (Veteran's Day theme)

2009-11-11T11:00:00.001-05:00

The theme for crzegrl's Grand Rounds this week is Veteran's Day.

The shrinky links:

doctors & mistakes (Medicine & Technology)
pharma ads & claims on twitter (HealthBlawg) ... also follow #FDAsm on Thur & Fri for coverage of the FDA's anticipated hearing on social media and Web2.0 (links for live streaming on HITshrink)
antidepressants for chronic pain (How to Cope with Pain)
love in the recovery room (Anesthesioboist) ... not really shrinky, just beautiful

Sliding Fees

2009-11-10T11:02:00.005-05:00

A lot of psychiatrists and other mental health professionals tell me they slide their fees, giving reduced rates to patients who can't otherwise afford to come. I want to ask: How do docs decide to do this? At clinics, scales are based on income (perhaps by family size), and just income, with a pre-set structure. But in private practice, this isn't usually the case (I don't think), and I wondered what other people do. In general, I've hesitated to slide my fees very much and this gets hard. Some of the patients I see live life without many luxuries-- rented homes, used cars, rare vacations. Sometimes it's a choice-- they choose not to work (when they could), and sometimes they are struggling quite hard to make ends meet, and yet they don't utter a word of concern about my fees. If anyone brings it up, it's me. Other times, patients are very verbal about their financial issues, how much they plan and calculate exactly what they can afford, and are very concerned about my fees and exactly what they can or can't afford. What's hard is that some of these same people are "strapped" because their life styles include many luxuries--boats, luxury cars, nice trips, a fine bottle of wine here or there, expensive tuitions, and maybe unexpected expenses. They come less then they should, or would like, because my fee is high. Maybe they've bitten off more then they should have (especially in the current economy) and are going through bankruptcy proceedings, or are simply worried about what the future might bring. Being tight on funds and the perception of what one can afford is based on many things, and so I'm putting this out not to get my own answers, but to ask how other people deal with this? Years ago I had a friend who was seeing a patient at a greatly reduced fee, only to discover that he lived in a much nicer house then she could afford-- it put some tension into the therapeutic relationship, I'm sure.

I Am Not 'One Of Them'

2009-11-09T13:44:00.004-05:00

Since the Fort Hood shooting I've been hearing and reading a lot in the media about 'compassion fatigue' and 'vicarious trauma'. I feel compelled to blog after reading yesterday's New York Times article on the topic, which I'm sure won't be the last.

The idea is that any mental health professional who spends their days listening to patients tell their stories of traumatic events will eventually end up having emotional difficulties from it as well. The other term for this is 'compassion fatigue', in other words losing the ability to empathize with others or becoming numb to trauma due to exposure to patients' traumatic stories. The Times article is careful to point out that vicarious trauma and compassion fatigue will not automatically lead one to become a killer.

Well, I'm relieved to hear that.

Over the years as both a forensic and correctional psychiatrist I've heard plenty of trauma-related stories. I've reviewed autopsy photos and crime scene photos and read police reports of violent offenses and watched videotapes of violent offenses. I've heard people talk about
their crimes and talked to victims of violent crimes (if they survived). People who have read my "What I Learned" posts know that the annual conference of the American Academy of Psychiatry and Law regularly features presentations about serial murderers, psychotic killers, crime scene investigation techniques and other topics that can be a bit gruesome.

If all 1700 forensic psychiatrists in this country are exposed to this regularly that's a whole lot of vicarious trauma. It's good to know I won't automatically become a spree killer.

Frankly, I wasn't worried.

Ch-Ch-Ch-Changes!

2009-11-08T13:37:00.004-05:00

The times they are a-changing....

Next year, the new parity laws for mental health will go into effect: health insurance must cover mental disorders the same when it covers other medical illnesses, without limits on visits, or higher co-pays. It remains to be seen how this will play out-- my fear has been that the response might be to simply eliminate mental health benefits from insurance policies. From the American Psychological Association (sorry, it was a pdf file so there is not a direct link) on the Wellstone-Domenici Parity Act of 2008 :

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (The “Wellstone-Domenici Parity Act”) will end health insurance benefits inequity between mental health/substance use disorders and medical/surgical benefits for group health plans with more than 50 employees. Under this new law a group health plan of 50 or more employees that provides both physical and mental health/ substance use benefits must ensure that all financial requirements and treatment limitations applicable to mental health/substance use disorder benefits are no more restrictive than those requirements and limitations placed on physical benefits. This means that equity in coverage will apply to all financial requirements, including lifetime and annual dollar limits, deductibles, copayments, coinsurance, and out-of-pocket expenses, and to all treatment limitations, including frequency of treatment, number of visits, days of coverage and other similar limits.

We don't know yet how this will play out...I hate that little clause "...that provides both physical and mental health/substance use benefits..." because it's left as an option. Would we tolerate a health insurance plan that excluded pneumonia or cancer? And it would be so nice if one could see a psychiatrist without pre-authorization (do you need pre-authorization to go to the doctor for your back pain or headaches or fever?) but my guess is that won't play out, since surgeries require pre-approval in many plans.

The New York Times has an optimistic piece on upcoming parity. Leslie Alderman writes in "In Anxious Times: Help for the Mind as Well as the Body:" Alderman writes:

The law’s changes can be good and not so good. Good, because you might have access to more care. Not so good if there are new requirements, like getting precertification for coverage, that place additional barriers to getting treatment, says Kaye Pestaina, vice president of health care compliance for the Segal Company, a benefits consulting firm.

“Employees should make sure their employer provides information to them about any new medical management rules,” Ms. Pestaina said.

Okay, so the House just passed the President's Health Care Reform bill (all 1,990 pages of it). What might this mean for psychiatry and how will parity play out in a newly-insured American?

One Of Us: Physicians Who Kill

2009-11-06T13:36:00.003-05:00

"I have already said that if you kill a doctor, all the doctors are instantly on your neck. But what if the man who does the killing is a physician himself? That complicates the situation most damnably..."

---Foursquare: The Story of a Fourfold Life by John Oliver

I've been reading, along with everybody else, the story of the Army major and psychiatrist Dr. Nidal Hasan who killed thirteen people in a spree shooting at Fort Hood yesterday. Let me say first that I've never met Dr. Hasan and know nothing about him; I have no particular information or insights about this offense beyond what I've read in the media.

The CNN article today interviewed two of Dr. Hasan's patients, who both said nothing but glowing things about him and his care. I've blogged about spree killers before ("Shooter Psychology") but this case is different. It got my thinking about the general issue of physicians who kill.

Physician killers are certainly a relative rarity, but they are not unknown. Dr. Jack Kevorkian is probably the most famous here in the United States, but in the United Kingdom there was the case of Dr. Harold Shipman. Dr. Shipman forged the will of, and then killed, several elderly female patients. Then there was Michael Swango, a serial poisoner who killed his patients specifically so that he could take credit for his heroic "resuscitation" efforts. As far back as 1920 Dr. John Oliver wrote about an anonymous psychiatrist colleague who killed another physician and was found legally insane. The quote at the start of this post is from Dr. Oliver's autobiography were he discussed the case. For anyone really fascinated by the topic, I refer you to the book Demon Doctors: Physician Serial Killers. I haven't read it myself so I can't vouch for it; feel free to write in reviews.

But I digress. Getting back to what happened at Fort Hood, the news reports don't indicate anything to suggest that Dr. Hasan was psychotic, motivated by greed or financial gain or out of a need to be a hero. He wasn't an infantryman who had been exposed to combat and who might have been terrified of going back to a traumatic environment. He was educated and presumably in a better financial and social situation than most of the patients he treated, unlike many of my murderer patients who have burned multiple social bridges prior to the killing.

Regardless, a killing by a physician---particularly by a psychiatrist---creates a bizarre aftermath. The military is sending mental health professionals to counsel the victims and witnesses; I'd be willing to bet those military mental health professionals will be required to check their weapons at the door.

2009-11-05T19:42:00.001-05:00

Here is an excellent article about preparing for testimony, for anyone
who has to testify at civil commitment hearings:

http://www.currentpsychiatry.com/article_pages.asp?AID=8091

One Offender's Story: Not Sick Enough

2009-11-05T10:17:00.001-05:00

I don't blog about patients, so I was pleased to find this excellent story about one mentally ill offender covered by American RadioWorks. I don't know and have never met this prisoner, but his story is similar to many of those I evaluate and treat.

http://americanradioworks.publicradio.org/features/mentally_ill/stories/notsick1.html

Too Interesting For Twitter

2009-11-05T07:03:00.003-05:00

I had to put this up on the blog because it was just too quirky to Tweet. A prisoner in the U.K. filed suit to request visitation rights for his cat:

Cat Banned From Visiting

The Accessible Psychiatry Project

2009-11-04T11:09:00.005-05:00

We've decided we could use an umbrella organization to explain what we do in a more official capacity. What do you think? And yes, the podcast will be back, we're just trying to keep our heads above water with getting the manuscript done for the book, blogging, and the rest of life!
----------------------

The Accessible Psychiatry Project

Encouraging dialogue about psychiatry across media.

Mission Statement:

The Accessible Psychiatry Project strives to encourage dialogue about psychiatric disorders and their treatment in order to explore issues of controversy and misunderstanding in our field. Through open dialogue, in both new media and old, we hope to foster awareness about the work psychiatrists do, and to decrease stigma associated with the treatment of mental disorders.

Components of The Accessible Psychiatry Project include:

Shrink Rap: a blog by psychiatrists, for psychiatrists. April, 2006- present—currently over 1100 posts on a wide variety of mental health topics.

Shrink Rap: http://psychiatrist-blog.blogspot.com/

Shrink Rap gets approximately 2,000 unique visitors per week. Readers are not limited to psychiatrists

My Three Shrinks podcast: a regularly aired show featuring 3 psychiatrists. Other mental health professionals have made guest appearances.

My Three Shrinks: http://MyThreeShrinks.com/

November, 2006- present, 48 episodes aired,

10,000 downloads/month

Featured on the Itunes Medical Podcasts Webpage

ShrinkRapRoy Twitters about technology and healthcare.

ClinkShrink Twitters about issues related to psychiatry and the law.

Off the Couch: Three Psychiatrists Discuss Their Work. In process, to be published by Johns Hopkins University Press, 2011.

What I Learned Part 4

2009-11-01T12:05:00.002-05:00

I attended a great lecture on the history of forensic psychiatry.
Prior to 1825 most forensic experts were providing testimony on
relatives or former patients. There was a woman who tried to kill King
George III and was found insane. Benjamin Rush promoted the use of the
"tranquilizing chair".

Homeland Security is moving into the old St. Elizabeth's Hospital.
There's something weirdly appropriate about them being in a
psychiatric facility. James Hadfield killed another patient and later
escaped but was recaptured. Edward Oxford tried to kill Queen Victoria
and was found insane. He was ultimately discharged from the hospital
and immigrated to Australia.

It's estimated that there are150 victims of Munchausen's by proxy
every year. Most victims are under the age of five.

A surprising number of surgeons have performed their own procedures
including appendectomies and herniorhaphies.

Rethinking Antidepressants

2009-11-01T11:48:00.002-05:00

Thanks to Henry for sending this link.

On cnet news, Elizabeth Armstrong Moore writes about research presented at this month's Neuroscience conference in Chicago:

Depression researcher Eva Redei presented research at the Neuroscience 2009 conference in Chicago this week that calls into question two tenets of depression science: that stressful life events are a major cause of depression, and that an imbalance in neurotransmitters triggers depressive symptoms.

Armstrong goes on to report that the research looks at the overlap of genes in RATS (not peeps) and notes that antidepressants work better for stress then depression and the genetic overlap between the two is minimal (--oh, why isn't Roy writing this, he's so much more eloquent than I am about the genetic stuff).
Armstrong goes on to say:

To test the long-held belief that stress is a major cause of depression, Redei looked for similarities between these two sets of genes. Out of more than 30,000 genes on the microarray, 254 were related to stress and 1,275 to depression. Only 5 were found in both samples.

"This finding is clear evidence that at least in an animal model, chronic stress does not cause the same molecular changes that depression does," Redei says. She is now looking at the genes that differ in the depressed rats so that she can narrow down targets for drug development.

Antidepressants are also often ineffective, Redei says, because they aim to boost the neurotransmitters serotonin, norepinephrine, and dopamine, whose reduced levels have been associated with depression. But this strategy is now also being called into question.

It's sort of news to me that we thought stress "causes" depression. I guess I thought extreme stressors (as opposed to general 'stress') can precipitate depression in those inclined to become depressed. Many people suffer extreme distress without getting major depression and many people with histories of major depression weather severe storms without a recurrence. What is nice about this research is that it challenges us to think in new ways, and I think sometimes research gets hooked around theories that aren't definitely proven and creativity gets stifled. Anything that nudges that can't be bad....

What I Learned Part 3

2009-10-31T20:43:00.002-04:00

Psychiatric evaluations were done on all homicide defendants over five
years in one Pennsylvania county. Forty-three percent of defendants
had no Axis I disorder.

One 300 mg pill of Wellbutrin sold in the underground economy of the
South Dakota state prison system is worth the equivalent of one week
of inmate wages.

Male and female homicide offenders are exposed to physical abuse and
traumatic events at equal rates in childhood, but women are less
likely to exhibit antisocial and aggressive behavior in childhood.

In California, the law allows jails to be considered "treatment
facilities" for the purposes of involuntary medication.

Reed Elsevier owns Lexis Nexis and ChoicePoint, the two biggest
information databases in the country. In Australia lawyers are able to
serve subpoenas through Facebook.

Twenty-two states have laws allowing for psychiatric advanced
directives.

A one year followup study of offenders under community supervision
showed that about half were on prescribed medication. A quarter of the
prescriptions were for controlled substances, generally Xanax or
Klonopin prescribed by a family physician or an ER. Intravenous drug
use was rare. This study was done on 336 offenders in Iowa, where 98%
of citizens have a high school diploma. Their offenders are more
educated than the average Baltimore citizen. The average offender IQ
was 108.

Univ of Conn did a study of psychiatry residents rotating at a prison
outpatient clinic and compared their ratings of the rotation to
rotations at free society sites. The prison clinic had higher ratings
on all measures---patient diversity, case load, safety and other
factors. Half of the students went on to work in the public sector.

(The pumpkin was added by Dinah, but it was carved by ClinkShrink...
Happy Halloween from the Shrink Rappers!)

What I Learned Part 2

2009-10-30T18:24:00.001-04:00

Notes from the second day of the American Academy of Psychiatry and Law.

The only psychiatric diagnosis not related to an increased risk of
suicide is mental retardation. Poor David Carradine got a mention
during the lecture on autoerotic asphyxia. Menninger talked about the
"three wishes" of suicide: to escape pain, to express rage, and to be
martyred (when provoking others to kill him). Five percent of all
suicides happen in the hospital. The legal idea of "proximate cause"
consists of the "cause in fact" (the poor treatment) and the issue of
foreseeability. HIPAA allows disclosure of information without consent
for purposes of treatment (like to do a risk assessment). HIPAA was
amended in 2002 to allow this. Many states allow disclosure without
consent in emergencies.

Humans and functional MRI are equally poor at predicting human
deception in an experimental poker bluff paradigm.

Georgetown medical school requires all their students to have an
iTouch or iPhone. Dang, that's progress!

The best predictor of competency restoration is the cumulative days of
length of stay. (Longer LOS means less restorable.) Predictors of non-
restorability are older age, mental retardation and a diagnosis of
schizophrenia.

The forensic sciences sampler is always the most fun and interesting
presentation for me. This year's topic was the investigtion of fires
and bombing. There is a local company, Combustion Science and
Engineering, which does computer modelling of these incidents.
Psychiatrists use psychodynamics, fire investigators use "fire
dynamics" or fire behavior. They consider witness reports, burn
patterns and electrical arc patterns to determine an origin and cause
of the fire. People who die within the compartment of origin tend to
die of heat injuries while outside the compartment they die of carbon
monoxide poisoning. Dr. Doug Ubelaker, a forensic anthropologist from
the Smithsonian Museum of Natural History, talked about human
identification of fire victims. When dry bones burn they get
longitudinal fractures, when flesh-covered bones burn they get
transverse fractures.

In the early days of the FBI the Smithsonian scientists were routinely
"loaned out" to help investigators.

Fetal kidnapping is when pregnant women are killed for their babies.
Out of 18 reported cases, only one defendant was legally insane.

It's never a good idea for your mistress to die under mysterious
circumstances even if you didn't kill her.

Kierkegaard today....

2009-10-30T10:27:00.001-04:00

I'm trying to schedule my posts around ClinkShrink's AAPL updates.

From the NYTimes, here's a piece by Gordon Marino on....What if Kierkegaard were alive today? Would he YouTube, Facebook, Twitter, take Prozac and be done with it?

Marino writes:

Each of us is subject to the weather of our own moods. Clearly, Kierkegaard thought that the darkling sky of his inner life was very much due to his father’s morbidity. But the issue of spiritual health looms up with regard to the way that we relate to our emotional lives. Again, for Kierkegaard, despair is not a feeling, but an attitude, a posture towards ourselves. The man who did not become Caesar, the applicant refused by medical school, all experience profound disappointment. But the spiritual travails only begin when that chagrin consumes the awareness that we are something more than our emotions and projects. Does the depressive identify himself completely with his melancholy? Has the never ending blizzard of inexplicable sad thoughts caused him to give up on himself, and to see his suffering as a kind of fever without significance?

If so, Kierkegaard would bid him to consider a spiritual consultation on his despair, to go along with his trip to the mental health clinic.

What I Learned Part 1

2009-10-29T18:01:00.001-04:00

Here's a brief summary of tidbits from the first day of the American
Academy of Psychiatry and Law conference.

First, there was an interesting keynote by Dr. Pat Recupero regarding
how to incorporate questions about the use of the Internet into the
mental status examination and the ethics of googling patients. (Shrink
Rap reader?)

The Indiana v Edwards case is a popular topic for presentation.
Defendants who represent themselves at trial are more likely to be
convicted of misdemeanors than felonies. Lots of discussion about how
pro se competence should be assessed and what the standard should be.

Got to meet and listen to Dr. Steve Morse, doing some of the most
fascinating research in forensic neuroscience. He stated functional
MRI will likely never be determinative of any legal issue. Favorite
quote: "Brains don't kill people, people kill people." Followed by:
"The only thing we know for sure about the mind and the brain is that
when the brain is dead, the mind is gone."

Six Federal jurisdictions have case law to bar third party observers
(ie lawyers) from forensic evaluations.

There are still people writing books about ritual cult abuse. They are
still not acknowledging that some claims may not be true, not even
after multimillion dollar malpractice actions for implantation of
false memories and exoneration of alleged perpetrators.

There was a presentation about expert witnesses' transference
reactions to attorneys and defendants. I think this is a pretty broad
stretch of the term.

Interesting historical overview of multiple personality disorder. The
patient Sybil had her sessions recorded. Her psychiatrist, Dr. Wilbur,
can be heard invoking and assigning names to her alters. The patient
Eve, Chris Sizemore, later wrote an autobiography repudiating her
diagnosis. Fifty-seven percent of audience (forensic psychiatrists)
did not believe in the disorder. Fifteen percent of surveyed general
psychiatrists think dissociative identity disorder should be removed
from the DSM. There was discussion of the role of the media and the
book Courage to Heal in precipitating the DID epidemic. DID experts
themselves disagree about the literal reality of satanic ritual abuse.
Some say this is a metaphor for severe psychological trauma. The FBI
division for offenses against children has never found evidence of
such cults.

Burgus v Braun is a landmark case for anyone working with trauma
patients. It resulted in a 10.3 million dollar settlement against
therapists for malpractice and Dr. Braun was expelled from the APA.