Prison Poetry

Recently there was a little problem in one of our local facilities. Nobody died, but the incident caused the officers in my facility to reminisce about fights they've had to break up in the past. I overheard some of the conversation and the result is this poem, direct from the officers' mouths:

Two of You and the Gate is Locked

200 guys in the yard, two of you and the gate is locked
You had two fights over here, three fights over there, it was like May Day...
It wasn't against us, it was BGF but we still had to stop it
It was over something small, one guy had a beef
That's when the weapons came out
The officer opened the gate to let him out
"I couldn't stand there and see the guy stabbed up"
They kicked the gate open
That's how the fight got to the compound
You gotta contain it
The gates lock you ain't going no where
They hit the doors, you contain it
You ain't going no where
You in there

Meditation: Does it Do Anything?

Meditation sounds like a great idea from the perspective of a psychiatrist: anything that calms and focuses the mind is a good thing (and without pharmaceuticals: even better!).

Personally, I tried Transcendental Meditation as a kid...more to do with my mother than with me...and found it to be boring. I have trouble keeping my thoughts still. They wander to what I want for dinner and should I write about this on Shrink Rap and will Clink and Victor ever eat crabcakes with me again and did I remember to give my last patient informed consent and a zillion other things. Holding my thoughts still is work.

The New York Times Well blog has an article on Meditation and Brain Changes. In "How Meditation May Change the Brain," Sindya N. Bhanoo writes:
The researchers report that those who meditated for about 30 minutes a day for eight weeks had measurable changes in gray-matter density in parts of the brain associated with memory, sense of self, empathy and stress. The findings will appear in the Jan. 30 issue of Psychiatry Research: Neuroimaging.

M.R.I. brain scans taken before and after the participants’ meditation regimen found increased gray matter in the hippocampus, an area important for learning and memory. The images also showed a reduction of gray matter in the amygdala, a region connected to anxiety and stress. A control group that did not practice meditation showed no such changes.

-------Lower stress, lower blood pressure, higher empathy.... I may have to give meditation another try. The cartoon above, by the way, shows Roy leading a meditation session. Now there's a thought.

Prescribing Psychotherapy: Today's Grand Rounds at Johns Hopkins

Today, I heard Dr. Meg Chisholm give Grand Rounds at Johns Hopkins Hospital on "Prescribing Psychotherapy." Coming at it from an obviously pro-psychiatrist-as-psychotherapist bias, Dr. Chisholm discussed the financial forces that encourage psychiatrists to have "med check only" practices. She mentioned Daniel Carlat's book, Unhinged, and even showed a picture of it --she gave it a thumbs up. Meg quoted someone as saying that psychiatrists are a precious resource and should only be doing time-efficient psychopharmacology and presumably cranking through those patients as fast as possible. She showed bar graphs that illustrate how fewer shrinks are doing psychotherapy and fewer patients are getting it. In terms of cost, it's not clear that split therapy is cheaper, and psychiatrist-for-meds/psychologist-for-therapy is actually more expensive than one-stop shrinking. She made the excellent point that while we know that a combination of therapy and meds works best for some conditions, we don't know if people do better if they have therapy with a psychiatrist or split therapy with two mental health professionals, and we really need outcome studies. Finally, she talked about what role, if any, psychotherapy training should have in the education of psychiatrists during residency.

There was a portrait of one of our mentors, the late Dr. Jerome Frank, a pioneer in psychotherapy researcher at Hopkins. Meg showed a photo from his younger days, but I chose one of Dr. Frank as I remember him (see above). There was the requisite cartoon of a psychoanalyst, and a picture of the fictional Dr. Paul Weston (Gabriel Byrne) over his In Treatment couch. Ah, but Meg has it wrong--- she's never watched the show yet her research revealed that Paul is a psychiatrist who prescribes medicine, but Paul is a psychologist with training in psychoanalysis. No prescription pad and we never see him actually practice psychoanalysis.

A psychologist in the audience made the point that the experience of doing split therapy is very different when done with different psychiatrists, and that it's a totally different event with a primary care doctor.

My thoughts? I had a few.

-- I don't like the implication that psychiatrists "should" practice a certain uniform way. "Should" every psychiatrist have to do psychotherapy even if they hate listening to the same patients? "Should" every psychiatrist see four patients per hour even if they would much rather practice psychotherapy? Doctors should do what they do best and like best, and it's fine if some docs do psychotherapy and some docs don't. Would we dictate that doctors in shortage fields shouldn't be allowed to hold administrative positions, do research that could be done by Ph.D's, take maternity leave, pursue hobbies, or have blogs?

--There's more to psychotherapy than just psychotherapy. Seeing patients often and for in-depth sessions allows for a more careful use of medications. In clinic settings where patients are seen infrequently and everyone's expectations are for 20 minute visits every 90 days, it's very difficult to address the question of whether a stable patient might do better on a different medication regimen. The risk of stopping a medication is often riskier than just continuing with the status quo. The question "Are you the best you can be?" doesn't get addressed and major changes in medications usually happen during periods of crisis or hospitalization.

--Psychotherapy continues to be an integral part of psychiatric treatment and residents should be required to learn to do psychotherapy even if they never plan to do it again. Without seeing patients through the process, a psychiatrist can't really appreciate the benefits or limitations, and the while we might like to think that psychotherapy is something one "prescribes" just like bactrim or synthroid or insulin, we all know that some people feel more helped by therapy than others and the importance of the interpersonal rapport is not something one can generically dictate.
----------------
Really good Grand Rounds.

Related Post: The Psychiatrist as Therapist

More Happiness, More Suicide?

On Tara Parker-Pope's NY Time Well Blog, she tells us that in places where people are the happiest, for example Denmark & Sweden, for example, have the highest happiness ranks, and the highest suicide rates. This is perplexing.

And apparently, the various United States are also ranked. New Jersey, where I grew up, is the 47th happiest state-- surprising given Full Serve gasoline, good pizza, and beaches. You were looking for something more out of life? Also it has the 47th suicide rate, so the miserable apparently tough it out.

Ms. Parker-Pope writes:

After analyzing the data, the researchers found a relationship between overall happiness and risk of suicide. In general, states with high levels of life satisfaction had higher suicide rates, according to the report, which has been accepted for publication in The Journal of Economic Behavior and Organization.
“Perhaps for those at the bottom end, in a way their situation may seem worse in relative terms, when compared with people who are close to them or their neighbors,’’ said Stephen Wu, associate professor of economics at Hamilton College. “For someone who is quite unhappy, the relative comparison may lead to more unhappiness and depression.”
Dr. Wu noted that other studies have found that people react differently to low income or unemployment depending on how common it is in their community. “If a lot more other people around them are unemployed, it doesn’t seem so devastating,’’ he said.

I'm not sure one idea leads to another. Could there be another factor here? How do suicide rates correlate with the availability of mental health professionals, for example? Or with the price of chocolate in a give region? And how happy is my state?

PT: Psychotherapy "Alive and Talking"

This month's Psychiatric Times continues the discussion [registration required :-( ] about the NY Times article on psychotherapy that Dinah and readers discussed on April 9. This time, our colleague, Ron Pies MD, authored this article which deconstructs the myths perpetrated in the NYT article, which interviewed a med check doctor who found it "sad" that his patients found him to be important to them in their lives (read the article for the full flavor).

I'm glad that Ron pointed out (as we have) that the 2008 Mojtabai and Olfson article -- which implied that only 11% of US outpatient psychiatrists provide psychotherapy -- was a misleading statistic. Why? Because they did not consider brief psychotherapy sessions (30 minutes or less) to be classified as "psychotherapy" for their session. Thus, a 90807 (45-50 min) is considered psychotherapy, but a 90805 (20-30 min) would not be considered so, even though the AMA's CPT manual defines it as psychotherapy. Also, brief and supportive forms of psychotherapy are often given even when only a "med check" is billed. Nonetheless, the sound bite from that article has been: "Only 11% of psychiatrists do psychotherapy". It just ain't true. As Mark Twain said, "There are three kinds of lies: lies, damned lies and statistics."

Psychiatrists and Media Statistics

Thank you to Angela Wilson and her Twitter feed for pointing me in the direction of this story.

The Palm Beach Post News is covering an investigation of prescribing habits of psychiatrists working in the juvenile justice system. The implication is that doctors who receive Medicaid funding are overprescribing atypical antipsychotics for detained juveniles. While the data looks compelling at first glance, I agree with Angela that it is incomplete.

The article implies there is a correlation between the number of scripts written and the amount of money paid to the doctors. This may be true, but there are no correlation statistics in the article to support this conclusion. They list the doctor's name, how many scripts he writes and how much money he received from the pharmaceutical industry, but there are no correlation measurements whatsoever.

The other problem with the article is that the number of scripts written is not placed into any context: How many hours per week does each doc spend in a juvenile facility? How many patients is he seeing? Is there a difference in the diagnoses per patient group (some docs may be seeing sicker kids)?

I'm not saying that that the pharmaceutical industry doesn't influence prescribing habits, or that it's good to overmedicate kids. My complaint is with how this story is presented. It's incomplete, so obviously incomplete (and I'm NOT a statistics maven!) that even I can pick it up. Sloppy, inflammatory journalism won't help these kids.

Daniel Carlat on Antipsychotic Medications for Agitation in Patients with Dementia

Lately, it seems like all the press about psychiatry in The New York Times is bad. We don't talk to our patients, we over-medicate them all from the children to the elderly, we all get bribes from drug companies. It's not that I don't think that these things don't happen, it's just that I don't like the sensational tones, and the one-sided nature of the presentation of psychiatrists as bad, the generalizations that it's "everyone," and the use of information taken out of context to make our practitioners look bad.

In a May 9th article Gardiner Harris writes:

More than half of the antipsychotics paid for by the federal Medicare program in the first half of 2007 were “erroneous,” the audit found, costing the program $116 million for those six months.

“Government, taxpayers, nursing home residents as well as their families and caregivers should be outraged and seek solutions,” Daniel R. Levinson, inspector general of the Department of Health and Human Services, wrote in announcing the audit results.

Mr. Levinson apparently feels the government should collect information on diagnoses so correct prescribing can be assessed.

On CNN today, Danny Carlat writes his own response in "In Defense of Antipsychotic Drugs for Dementia."

The story highlights include:

STORY HIGHLIGHTS

• Daniel Carlat: Report implies evil doctors are giving deadly drugs to nursing home patients
• But antipsychotics are most effective drug for calming agitation in dementia, he writes
• Carlat: No drugs are FDA-approved for this agitation, a terrible condition

Carlat writes:

But in this particular case, the Office of the Inspector General has it wrong, and Levinson's statements on behalf of Health and Human Services reflect an astonishingly poor understanding of the workings of medical care in general and psychiatric care in particular.

The unfortunate fact is that no medications are FDA-approved for the agitation of dementia, and yet the condition is common.

Although it's true that a prescription for antipsychotics to treat agitation in dementia is "off-label," this hardly means they are ineffective or that Medicare claims for these drugs are "erroneous." In fact, large placebo-controlled trials have shown that antipsychotics are the most effective medications for the agitation that often bedevils patients with dementia.

When these drugs are successful, they soothe the inner turmoil that makes life intolerable for these patients, improving their quality of life dramatically.

Physician Online Behavior: Professionalism and Social Media

Mark Ryan, a Virginia family physician, wrote a blog post for Mayo Clinic Center for Social Media three weeks ago, reviewing the many definitions of "professional behavior" for physicians and how that might apply to our social media interactions.

It is apparent to me that what is considered appropriate or not for physicians using social media (eg, should you friend a patient on Facebook?) is still being tested and figured out. However, Mark's post reminds us that there are certain principles that remain immutable, despite the technology.

Solitary Confinement

 

Sunny CA recently asked me my thoughts about the use of solitary confinement in light of allegations that this can cause mental illness.

My short answer to this is, "Don't believe everything you read in the media about solitary confinement."

When I first started working in corrections I started with the same assumption, that locking someone in a single cell might cause something called the "SHU syndrome". The exact symptoms that make up the SHU syndrome vary a bit but the gist of it is psychosis with disruptive or self-injurious behavior.

Once I had some experience under my belt working in maximum security and control unit environments, I started to question this theory because I just wasn't seeing the new onset psychosis that everybody suggested should be happening. I reviewed the literature and discovered that some of the articles that were repeatedly cited about this were written by psychiatrists who were plaintiff's experts in class action suits involving longterm segregation. I also found out that the articles describing SHU syndrome were no more than series of case report studies. In the classic Grassian article about solitary confinement, the author even admitted that he had to encourage the inmates to report their symptoms! And there were no well controlled studies about it. I did find a series of four papers in the British Medical Journal that did repeated measures of various psychological test batteries on inmates, and compaired scores against the subjects' accumulated incarceration history. These papers found no deleterious effects from confinement in general, but was not specific to segregated confinement. Another study from Canada (I think Wormith was the first author) found no negative effects, but this was a short term (just a few months) study.

The best designed research on the effects of longterm segregation was just published this past November. The University of Colorado researchers studied a few hundred inmates who were taken to disciplinary adjustment hearings and were at risk for longterm segreation. They compared those who were transferred to segregation with those who were returned to general population, and had an additional control group of inmates in the prison psychiatric hospital who also had disciplinary and behavioral problems. They compared the mentally ill inmates to the non-mentally ill inmates in all three settings over time (Ad Seg, Gen Pop and psych infirmary). They did testing every three months over the course of one year.

They used tests that measured eight different symptom dimensions, in addition to ratings done by the clinical and correctional staff (the BPRS).

Here, in a nutshell, are their findings as quoted from the executive summary with the "bottom-line" conclusions in bold-face:

"The results of this study were largely inconsistent with our hypotheses and the bulk of literature that indicates AS (administrative segregation) is extremely detrimental to inmates with and without mental illness. We hypothesized that inmates in segregation would experience greater psychological deterioration over time than comparison inmates, who were comprised of similar offenders confined in non‐segregation prisons."

"In examining change over time patterns, there was initial improvement in psychological well‐being across all study groups, with the bulk of the improvements occurring between the first and second testing periods, followed by relative stability for the remainder of the study. "

"We stated that offenders in segregation would develop an array of psychological symptoms consistent with the SHU syndrome. As already discussed, all of the study groups, with the exception of the GP NMI group, showed symptoms that were associated with the SHU syndrome. These elevations were present from the start and were more serious for the mentally ill than non‐mentally ill. In classifying people as improving, declining, or staying the same over time, the majority remained the same. There was a small percentage (7%) who worsened and a larger proportion (20%) who improved. Therefore, this study cannot attribute the presence of SHU symptoms to confinement in AS. The features of the SHU syndrome appear to describe the most disturbed offenders in prison, regardless of where they are housed. In fact, the group of offenders who were placed in a psychiatric care facility (SCCF) had the greatest degree of psychological disturbances and the greatest amount of negative change."

This study describes exactly what I see. The inmates who end up in solitary confinement have significant problems to begin with, but segregation doesn't necessarily make them worse.

The ACLU and other advocacy organizations are understandably not happy with this study and you can find the major criticisms just by Googling "Colorado solitary confinement." The study itself is not so easy to track down but I found a link Colorado Longterm Segregation study.

Thanks for asking the question Sunny, it's a topic that I've been particularly interested in.

The Special Needs Child

 

Oh, we're not kiddy shrinks, so this post is not really about children.  But I like the term, it implies that the person needs something more, that they have special-- presumably increased-- needs.  It says nothing about potential.  I use the term often, and sometimes with a bit of humor, to remind people that the playing field is not always level.  There are people who start any give race with a handicap-- a learning disability, dyslexia, major health problems, mental illnesses, horrible childhoods, addictions, -- and these set them on a slightly different course.  


Some people overcome tremendous adversity.  They function 'as if' they had no special needs.  They have stories that would let you understand if they didn't do very well in life, stories that would explain burying their heads in the sand, or crawling under a large rock.  Sometimes these special needs people are so driven to excel that they don't just hang in the race, they lead the pack, as if they had no problems as all.  They measure themselves against those without special needs and everyone forgets that they are racing with a bit of extra baggage and often very remarkable stories.  They are among the most resilient of people, and their stories are often inspirational.


Why is this a problem, or even a Shrink Rap post?  I suppose because the issues come up all the time, and they get to be problems when the special needs child gets so good at running the race "as if" they are not hindered by the weight of their problems that they come to expect nothing short of excellence. They run without the memory of their handicap and are particularly unforgiving of their lapses.  So what if one needs to rest, or if one doesn't finish the race first, or doesn't finish at all?  But even worse, their loved ones often come to expect so much that they may become critical if special needs child lags a bit here or there.


Sometimes it seems it's fine to simply say, "I have a special burden and I can't keep up right now."  


This is for Carrie who shared her remarkable narrative with me and for all the other people I know who expect so much of themselves in inspirational ways. 
And tonight, this is for Steve Jobs who gave the world so much until the very end of the fight.  

The Psychotropic Media Wars

 Just in case you haven't had enough of people ranting about the efficacy (or not) of psychotopic medications in the popular media, I thought I'd refer you over to an article by Dr. Harold Koplewicz on The Huffington Post.  Here's a quote:

Good studies for psychiatric treatments are desperately needed. In the meantime, we have patients, in our case children and adolescents, who desperately need help. These children may be out of control, overwhelmed by anxiety, dangerously aggressive, disorganized in their communication, floundering in school. We need to help them. Medications, often along with behavioral therapy, can have a transformative effect. If they don't help, we are not forced to continue using them. We would like to see objective research catch up with the clinical realities but can't wait until that happens. Furthermore, falling back on pure non-pharmacological treatment is not the better alternative, since these treatments have rarely undergone objective evaluation.

As to the issue of psychoactive drugs actually harming patients by altering their brain chemistry over the long term, which Angell posits, here too data is lacking. It makes no sense to forego present benefit because of undemonstrated future harms. We try to weigh the risks of psychoactive drug treatment against the risks of forgoing treatment. That risk often includes academic failure, dropping out of school, substance abuse and even suicide. Unfortunately, the risks of avoiding demonstrated useful treatments are not something critics, like Angell, consider.

Is This Depression?

Over on KevinMD, an anonymous doctor has post up called the Absence of Joy about his own problems with depression.  He writes:


For ten years I fought against the feeling that for long periods of time I was abnormally unimpressionable.  Not all the time, but certainly for moments. I was neither incredibly happy nor depressingly sad.  I put all this down to the stresses of making ends meet by moonlighting in ER’s, working impossible hours, studying for interminable exams, followed by the stresses of looming loan repayments, cash flow crises, parenting and marriage demands as my practice struggled to find its feet.

During moments of reflection I would question my condition, briefly consider depression as a factor, and then disregard it completely.  I was sleeping well.  I was not miserable.  Just stressed, like many of my colleagues.  Burn out was the diagnosis I chose for myself, and there seemed to be no easy option to deal with that.

But as the joy withdrew from my life, I was unable to identify the cause within.  I looked for other causes.  If the reason was not internal, it had to be external.  I found subtle fault with everyone around me, my wife, my kids, my career, my patients, my staff.  I considered changing my situation, leaving all of these, building another life, because this one did not appear to make me happy.
My wife saved me from myself.  Some ultimatums later, I was presented with a diagnosis of subclinical depression and began taking an SSRI.

He goes on to talk about how much better he feels and how much less labile his moods are.  He mentions things rolling off him like they'd roll off a duck's back, and of course we Shrink Rappers are big into ducks. 

So why am I writing about this blog post?  I think because I wasn't so sure I would have offered this patient medications.  Of course it's only a snapshot, and sometimes a recounting of symptoms on paper does not match the distress that a live person can convey, but the writer does not describe clinical major depression, what we think of as an illness.  He does a great job of describing existential angst, and makes no mention of whether he's had psychotherapy.  Perhaps he describes dysthymia (a low grade chronic depression that depletes the patient) but I wasn't totally sure.  I almost had the sense while reading that he's taking a happy pill that moves him to complacency. But the writer describes a huge relief, satisfaction with his outcome, and who am I to second guess? 

Just thought it might make for some good conversation here on Shrink Rap.  Do check out the whole post over on KevinMD by clicking here.

Looking for Psychiatrists for APA Talk in May on New Media

@ 2011 AVAM Kinetic Sculpture Race

I'm moderating a panel discussion about Psychiatrists and the New Media at the May 2012 APA Annual Meeting, and I have two slots left for the panel. It will include a brief presentation (5-7 min) from each participant, followed by a panel discussion and audience questions.

If you are a psychiatrist attending the meeting and would like to be on the panel, please email me (shrinkraproyATgmail) or comment here. I'll also write a blog piece next year with highlights from the session for our readers.


[At right, I shot this pic of a toddler fascinated by the bubbles from the bubble machine at the 2011 Kinetic Sculpture Race at the American Visionary Art Museum in Baltimore.]

No More Xanax

I'm posting this because Roy fell asleep at the wheel and missed the Xanax article on the front page of yesterday's  New York Times.  In "Abuse of Xanax Leads a Clinic to Halt Supply,"  Abby Goodnough writes about a clinic where they've stopped prescribing Xanax because to many people are abusing it.  Goodnough writes:

“It is such a drain on resources,” said Ms. Mink, whose employer, Seven Counties Services, serves some 30,000 patients in Louisville and the surrounding region. “You’re funneling a great deal of your energy into pacifying, educating, bumping heads with people over Xanax.”
Because of the clamor for the drug, and concern over the striking number of overdoses involving Xanax here and across the country, Seven Counties took an unusual step — its doctors stopped writing new prescriptions for Xanax and its generic version, alprazolam, in April and plan to wean patients off it completely by year’s end.

If you want to know how the Shrink Rappers feel about Xanax, do read Roy's post on Why Docs Don't like Xanax (Some of Us).  It's been our all-time most popular post.  


So I was a little (not a lot) surprised that this was "news."  I've worked in four public clinics-- I've never seen a prescription written for Xanax, and for the most part, the clinics where I've worked have had a sort of non-stated ban on prescribing controlled substances.  It's not that benzodiepines and stimulants are never helpful, but in the clinics, the issues concerning abuse, and the drain on the system gets to be very hard, plus we worry that the harm these medicines can do will be worse than the problems they 'cure.'   It's very rare that I've written for controlled substances, and I've never written for Xanax in a clinic, or seen a chart from another patient where Xanax was prescribed. I'd be shocked by the article, but during the two weeks I was in Louisiana after Katrina, I did see many patients who had been on high doses of long-standing Xanax that were prescribed by docs at community clinics, so I know it's done.  But you know, ClinkShrink doesn't like benzos at all, ever (per The Benzo Wars, if you'd like to hear us shriek at each other), and the rest of us Shrink Rappers don't like Xanax in particular.


Time to wake up, Roy.

Empathy and Air Travel

A few days ago, I ranted about how I was detained by security at an airport, then lost my computer.  I've put an update on the bottom of the that post: My Disasters, Natural and Otherwise.

So let me talk about my new friend, whom I've never met and whom I know pretty much nothing about, Steve Silberman, blogger over on Neurotribes.  Now I've never actually read much of Neurotribes, and maybe he express opinions that would make me feel ill, but when one of our readers pointed out the post called "Dear United Airlines: I Want My Kindle and My Dignity Back", I felt like I had found a soul mate in my distress over my lost laptop and the frustration I have felt in trying to inspire some sense of caring or empathy from TSA or the airlines. 

Mr. Silberman writes:

The metaphor of frogs that don’t notice the water around them is getting warmer until it’s boiling (and they’re cooked) is only an urban legend, say the vigilant debunkers at Snopes.com — but it’s an apt image for today’s frequent flyers. Schlepping their carry-ons through security mazes, standing shoeless with arms outstretched in bleeping machines, shrugging off dramatic confiscations of shampoo and toothpaste, and frantically rejiggering carefully-plotted itineraries at a moment’s notice, we’ve come to accept the current state of affairs as just another way that life sucks in the post-9/11 era. Never mind that I’m old enough to recall when a cross-country trip on an airplane, even in economy class, offered an opportunity to unwind and feel coddled in the lap of luxury for a few hours with a stratospheric view. Now I look forward to flying about as much as I look forward to a trip to the dentist.


Okay, Steve, it was nice to meet you. 

My Disasters, Natural and Otherwise, now updated.



Why I Am Happy That I Am Not a Child Psychiatrist

My hat goes off to kiddy shrinks.  It's a tough field, full of issues we don't see in adult psychiatry.  

Our comment section often buzzes with talk about the over-diagnosis of bipolar disorder in children and the ethics of giving psychotropic medications to children.  The Shrink Rappers never comment on these things.  Why?  Because we don't treat children.  I have no idea if the children being treated are mis-diagnosed, over-diagnosed, wrongly-diagnosed, or if the increase in treatment represents a good thing---- perhaps children who would have suffered terribly now are feeling better due to the option of medications.  I've certainly had adult patients tell me their children were treated with medications, the children have often eventually stopped the medications and emerged as productive adults.  Would they have outgrown their issues anyway.  Or did the treatment they received switch them from a bad place to a good place and enable them to carry on in a more adaptive way?  Ugh, my crystal ball is on back-order at Amazon!  

Why I'm Happy I'm Not A Child Psychiatrist:

• Two extra years of training (and being on overnight call)

• No extra pay.

• "Normal" or "well" children often display behaviors that look a lot like those of "ill" children.  Ever witnessed a temper tantrum? 

• Children often can't verbalize their feelings and they are inferred from behaviors. 

• Children are often subjected to the treatment, with all it's options for distress-- whether it be that therapy displaces soccer or that Risperdal causes sluggishness-- without the same open dialogue and choice that adults get.

• Children are often treated based on the distress of other people.

• Some illnesses in children are defined by the arbitrary standards of societal expectations.  There would be fewer hyperactive children if we didn't expect boys to sit still for long periods of time.

• It's very hard to differentiate a "phase" that will be outgrown from "pathology."  This is especially true in teenagers where some angst and rebellion are part of some people's journey.

• There are times when treatment is based on the reports of others (such as parents) and there is no guarantee that such reports are accurate or that the parent's expectations are reasonable/realistic, and parents can be quite demanding about the need for treatment and medications.

• It can be difficult dealing with the troubled parents of troubled children.

• Expanding on that, parents sometimes get angry and remove their children from treatment if it is suggested that they are part of the problem.

• I don't like treating people who don't want help and children are sometimes in treatment at the request of their parents, schools, or other agencies.  True for adults as well, but not in my office.

What Medicare Cuts May Mean For Patients Who See Psychiatrists

Over on Shrink Rap News, Roy wrote a post about proposed Medicare cuts.  He continued the conversation here on Shrink Rap.  

I want to expand on the discussion in what I hope will be easy-to-understand terms.  Why would anyone who is not a doctor even care what Medicare reimburses their docs?  Let me tell you why you might care.

Doctors all have one of four designated categories within the Medicare system:
1) The doc participates and accepts Medicare assignment.  The fee for the service is set by Medicare, the patient makes a co-pay and the doctor bills Medicare and gets the rest of the fee from Medicare.
2) The doctor is "non-participating" --which is a deceptive term, because non-participating docs are within the Medicare system.  The fee for the service is set by Medicare and is typically 5% less then the fee for participating docs, but the patient pays the Medicare fee in full to the doctor, the doctor files a claim with Medicare, and Medicare reimburses the patient for a portion of the fee. 
3) The doctor has formally opted-out.  In this case, the doctor charges the same fee that every other patient is charged, the patient pays the doctor in full.  No forms are filed to Medicare and the patient receives no reimbursement at all.  A doctor who opts in one setting is opted out in all settings, so one can't opt out in private practice and also work in a clinic where Medicare is accepted. 
4) The doctor never files anything with Medicare.  He can not see Medicare patients at all, ever, in any setting.  Perhaps he can see patients for free(?), but no money can change hands and no forms get filed.  This is not the usual.


The current proposal is for a 30% cut in provider fees for 2012.  Oh, we dance this dance every year.  But this year, the thinking is that it may stick.  As is stands now, the current Medicare fee for a non-participating provider in the area where we live, for a 50 minute psychotherapy session, with medication management, in a non-facility (meaning, for example, a private practice that is not hospital-based) is $120.96.  This fee is notably lower than going community rates, and because of this, many psychiatrists who practice psychotherapy have opted out: they can charge what they'd like and they don't have to deal with the hassles of filing any paperwork.  Oh, but it's not just psychiatrists, some internists have opted out of Medicare.  It means that when you hit 65, either you pay your doctor out-of-pocket, or you change doctors.


Currently, it's hard for patients to find psychiatrists who participate with Medicare, and those who do often limit new Medicare patients. A doctor can come highly recommended, and you may be a multi-millionaire, but that doesn't matter, because once a doctor is in Medicare as either participating or non-participating, the fee is set by Medicare and being rich doesn't buy you in, because all Medicare patients pay the same fee. 

If the fee drops so that an hour of work is reimbursed at $84.67, a 30% decrease, more psychiatrists will opt out.  From the doctor's point of view, they kind of win: if they can hold on to a big enough patient base, they can charge their usual (generally higher) fees and they don't have to hassle with claims.  From Medicare's perspective, they definitely win: patients are forced to get care outside the system and they reimburse nothing.  It's not like going out-of-network with your private insurance where they will still pay for services, perhaps at a lower rate or with a higher deductible, but they do compensate for a chunk of the care.  Those doctors who remain in the system are those who can make it work for them--- they see patients for Pharmacologic Management with a code that does not have a time requirement and cram as many patients in as fast as they can see them.  But as SteveMD has pointed out in his comment, when fees drop by 30%, even the workhorse psychiatrists who can go at an exhausting pace of 4-5 patients per hour will be making much less money to provide one-size-fits-all 10 minutes-with-a-shrink care. 

From the patient's point of view: they lose.  Suddenly their doctor doesn't accept Medicare.  They now get hit with a much higher fee and they get no insurance reimbursement.  This is why you should care.
------
On a lighter note, the photo above is a picture of Oreo, a very sweet Havenese poochie we befriended during our book signing at the Baltimore Book Festival today.  I put a photo of us up on our Facebook page.....one more illustration of Roy ragging on me.  Please do visit our FB page at Shrink Rap Book and by all means, "Like" us!

He's Gone

At 8:30 last night I got the news. It came from somebody who knew me quite well and knew my hardcore loyalty to Apple, enough to call me a "Steve Jobs Apple toady bootlicker." A good friend, yes. He told me: Steve Jobs was dead.

Wow. I remember when John Lennon was killed and I'll remember getting this news.

Steve Jobs has been part of my professional and personal lives for 25 years. I got my first Mac in 1986, during my second year of medical school. It was a huge decision, and even with a student discount a tremendously expensive thing to do. It was a decision I've never regretted. I still have that machine.

The day I went to pick up my new machine they held a special event at the university hockey stadium. The whole place was filled with aisles of Macs stacked six feet high. People were lined up around the block to pick up their new machines. The only time I've seen anything like that was at the opening of the first Apple store in 2001. I was standing in line at Tyson's Corner, fortunately not at the end which curled around the second floor and down the stairs. The waiting time to get in was rumored to be three hours, and there was security in place to make sure the store stayed below the fire marshal's limit of people in the store.

The Apple years without Steve Jobs were grim. A series of five CEO's successively drove the company into the ground. The quality of the machines dropped, there were recalls for broken parts, bad monitors, stuff that never would have happened under Steve. (OK, the Apple Newton eventually became the prototype for the Palm Pilot---using an operating system designed by former Apple engineers---but it never quite got it right.)

Then he came back. Just in time, like Superman coming back just as the bomb is about to explode, to save the world. We got that weird-looking first-ever all-in-one pyramidal iMac. We got OS X, one of the most stable operating systems I've ever used. We got iPods and iPhones and iTunes (without which our My Three Shrinks podcast would never have happened). We got the iPad. We got the software. It just happened.

So here we are. We three Shrink Rappers all use Apple products. We edit podcasts with Garage Band, have iPhones, use MacBooks. Our iPhone edition of Grand Rounds was one of most popular posts (complete with clickable iPhone buttons). Technology for non-geeks.

There's not much else to say. If there is, the Twittersphere has it covered---it's been nothing but mourning for hours after the news broke.

He's gone.

Goodbye.

And thanks.

October 10th: World Mental Health Day

U N I T E D   N A T I O N S                    N A T I O N S   U N I E S

THE SECRETARY-GENERAL

--

MESSAGE ON WORLD MENTAL HEALTH DAY

10 October 2011

There is no health without mental health.  Mental disorders are major contributors to illness and premature death, and are responsible for 13 percent of the global disease burden.  With the global economic downturn – and associated austerity measures – the risks for mental ill-health are rising around the globe.

Poverty, unemployment, conflict and war all adversely affect mental health.  In addition, the chronic, disabling nature of mental disorders often places a debilitating financial burden on individuals and households.  Furthermore, individuals with mental health problems – and their families – endure stigma, discrimination and victimization, depriving them of their political and civil rights and constraining their ability to participate in the public life of their societies.

Resources allocated for mental health by governments and civil society are habitually too little, both in human and financial terms.  Recent data from the World Health Organisation clearly show that the proportion of health budgets devoted to mental health is inadequate.  Most low- and middle-income countries spend less than 2 per cent, and many countries have less than one mental health specialist per one million people.

The theme of this World Mental Health Day is “Investing in mental health”.  We cannot expect improvement in global mental health statistics unless we increase financial and other support for promoting mental health and providing adequate services to those who need them.  Deaths, disability and distress caused by mental disorders need to find their rightful place in the public health agenda.

Mental illnesses can be treated effectively.  We have the knowledge.  Feasible, affordable and cost-effective measures for preventing and treating mental disorders exist, and are being implemented, for example through WHO's Mental Health Gap Action Programme (mhGAP).  However, if we are to move decisively from evidence to action, we need strong leadership, enhanced partnerships and the commitment of new resources.  Let us pledge today to invest in mental health.  The returns will be substantial.

Toys!!!

I think I have officially caught the Toy Disease.  It's taken a long time, but oy, I've got a bad case.  

For starters, after losing my Macbook, I bought a new one and decided I should simultaneously fix all my techno problems.  My phone had terrible reception and many of my calls.  I got a new Samsung phone, a touch screen, and it was awful.  It dropped my calls, it switched to speaker if my face touched the screen, I couldn't cradle it on my shoulder and talk to Camel while I cooked dinner...not good.  I surrendered, and after many years of happiness with my dumb phones, I gave in, risked the last vestiges of anything that might resemble sanity, and bought an iPhone.  Excited, I came home to have teenager greet me with, "Why did you get that, a new iPhone is coming out in 3 weeks."  So, I went back to the phone store (I am now the most-recognized customer), and ordered a new iPhone 4s and am eagerly anticipating the arrival of the new phone.  I can't wait to meet Siri and have her negotiate all my problems. 

Okay, and a while back, I asked Shrink Rap readers to help me decide between a Nook and a Kindle.  I decided on a Kindle, but never got one.  And then I read about the new Kindle Fire.  Oy.  I've pre-ordered one.  

Now I'm thinking I "need" Apple TV.  What is wrong with me?


Finally, I have some questions for our readers:

• Dropbox or iCloud?
• Apple TV: yes? no?
• How's it going with Siri?  What's the coolest thing you've asked it (?her) to do?

• 
  

This is how i Feel today!

There's an article in the New York Times called If You're Happy and You Know it, Must I Know Too?  I thought it would be a story about moods, but it's a story about writing and emoticons by serious people.  One person said they hated them and un-friends anyone who uses emoticons or LOL or OMG.  Fortunately this person is not my friend, so I don't have to worry about this, but I did think that life is too short to expend a lot of energy on such thing.  And the article talked about how emoticons were initially used by teens and "frothy adults."  What's a frothy adult?  I thought beers were frothy.  So I looked it up and I learned that frothy means "light and entertaining but of little substance."  LOL!  


So Shrink Rap will be adding a new feature.  We will be adding a feature to our sidebar where every day all three Shrink Rappers and the Duck will be posting an emoticon to describe our moods.  I'm guessing we'll have to remind Roy sometimes, but he may be able to find an app that lets him post his mood from his iPhone, and then he may decide to change it hourly.  This will enable readers to better decipher our posts within the context of our mood states.  Hope you enjoy this new feature.  And please do end your comments with a smiley face or other emoticon.

Ups and Downs--The Bipolar Diagnosis

I want to thank all of the people who commented on my post What is Bipolar Disorder.  Your comments were tremendously helpful.  The descriptions of what it feels like to have this illness were incredible-- vivid, heartfelt, almost a mix of poetry and misery-- the stories were told in a way that I don't often hear in clinical settings.  So, thank you.  And if you're someone who doesn't read the comment section of blogs, I would urge you to make an exception for this post.  The comments speak to what an intelligent, educated, and articulate readership we are lucky enough to have join us here, and the commenters make the experience of difficult mood states come alive in a way it is so hard to do with words.  A little bickering (it wouldn't be Shrink Rap without that!), but I want to point out that the issues that inspired the bickering are exactly the concerns we address in figuring out the usefulness of the expanded bipolar diagnosis.


That said,  I wrote my article for Clinical Psychiatry News, called Rethinking Bipolarity.  If you click the link at the end, it will cycle you back to the What is Bipolar post.  Let me know how I did?

And thank you, again.  Thank you also to Dr. Dean MacKinnon, of the Johns Hopkins Mood Disorders Center and author of Trouble in Mind for previewing the article for me.

More on How Lousy Psychiatrists are at Determining Prognosis

A few days ago I put up my post on the Clinical Psychiatry News website on Rethinking Bipolarity.  I talked about how we've expanded the diagnosis so that now it captures so many problems as to make the diagnosis imprecise and I talked about how we really can't predict prognosis.  In the same vein, the front page of the New York Times has an article about people with schizophrenia who do better if they keep busy with busy careers, even if they are very stressful.  In a High Profile Executive Job as Defense Against Mental Illness, Benedict Carey writes:

Now, a group of people with the diagnosis is showing researchers a previously hidden dimension of the story: how the disorder can be managed while people build full, successful lives. The continuing study — a joint project of the University of California, Los Angeles; the University of Southern California; and the Department of Veterans Affairs — follows a group of 20 people with the diagnosis, including two doctors, a lawyer and a chief executive, Ms. Myrick.


The study has already forced its authors to discard some of their assumptions about living with schizophrenia. “It’s just embarrassing,” said Dr. Stephen R. Marder, director of the psychosis section at U.C.L.A.’s Semel Institute for Neuroscience and Human Behavior, a psychiatrist with the V.A. Greater Los Angeles Healthcare System and one of the authors of the study. “For years, we as psychiatrists have been telling people with a diagnosis what to expect; we’ve been telling them who they are, how to change their lives — and it was bad information” for many people. 

It's a good article, but I have one gripe with it (...ah, for me to have only one gripe with an article by Mr. Carey is close to amazing).  He makes it sound like people with schizophrenia have chosen less stressful jobs because that's what doctors recommend.  I think some people with schizophrenia lose their motivation to work at any job because it's one symptom of the illness.  Like bipolar disorder,  schizophrenia and schizoaffective illness seem to play out differently in different individuals.  As a field, our crystal balls don't seem to work very well. 

Destined to Disappoint?

Tomorrow, I'm going to pick up my new iPhone.  Mind you, I've been an iPhone owner for about 4 weeks now, and I'm returning a month-old iPhone 4 to get a 4s.  I can't wait, the phone arrived today and I've had to restrain myself from going out in the rain tonight and waiting until tomorrow.


I'm looking forward to having Siri be my personal assistant.  For weeks now, whenever I look things up or schedule an appointment or send an email or text, I wonder: Will Siri do this?  Will it work?  Can I tell her to send text messages?  Do I need to switch back to iCal from my Google Calendar?  No big deal, right---I'll just tell her to schedule things and my calendar will be revised and moved in a matter of minutes?  Can Siri phone in prescriptions?  Can she preauthorize my life?   I'm excited as though I'm about to move in with a spouse in an arranged marriage. 


So have I built this up in my imagination? Is it too good to be true? You can bet that if Siri texts, Roy and Clink will be the first to know my new iPhone has arrived.  I'm finally going to be the kid on the blog with the newest toy: it's never happened before!

-----------------------
On another note, I am feeling rather cool.  Our Shrink Rap book was scraped by a Hip Hop site!
 --------------------------
David would like to be credited with the title for this post.  Who knew?

What I Learned Part II

Psychiatry residents on the APA listserv were surveyed about their experiences with social media. 9.7% of residents had gotten friend requests from patients. The remaining residents were asked what they would do if they got such requests. 85% of residents said they would automatically ignore them. 15% said they would discuss the request with the patient, then decline it. Less than 3% of residents received any training about proper social media use in residency. Half admitted googling their patients.

One poster presented the results of a one year study of four major media outlets: the New York Times, the LA Times, USA Today and Fox News. The outlets were culled for articles related to mental illness and violence. The stories were scored according to how many contained one of the follow true facts about mental illness and violence:
1. The majority of mentally ill are never violent.
2. People with mental illnesses are more likely to be victims of violence than perpetrators
3. People with mental illnesses are more likely to be violent against themselves than against others
4. When violent, they are more likely to victimize family than strangers.
Fewer than five percent of the articles contained any of these facts.

The state of New York has successfully used electronic monitoring and regular clinician feedback to reduce the use of polypharmacy in the state prison system.

All state prison systems were surveyed regarding their policies regarding pornography. Of 43 responding states, all banned material that represented a risk to institutional safety and security. There was high variability regarding allowed visual or verbal depictions of sexual acts. There is no published data to support any policy link between prison safety and the presence of pornography.

Crisis intervention training for police is thought to be helpful to reduce incidents of violent outcomes when responding to acutely mentally ill people, but the content of the training varies between program and lacks consistency. There also needs to be more outcome studies to learn if these programs do actually divert mentally ill people out of the criminal justice system.

The PCL-R is coming under pressure as a risk prediction tool. There was a great pro-con debate about this presented by a panel of Broadmoor Hospital psychiatrists. Although interrater reliability is 0.8, there is still significant variance in scores and this could be enough to cause inconsistency when using cutoff scores to determine readiness for release from their severe personality disorder program. It stood out as a risk prediction tool in the 1990's because it was the only one of its kind, but newer tools are being developed with better ROC-AUC scores.

Lastly, multiple personality disorder is coming back. In spite of recent books such as Sybil Exposed, Creating Hysteria and I'm Eve, which document the role the therapist played in the creation or course of the disorder, one presentation today still featured a criminal defendant thought to suffer from multiple personality disorder. This presentation would have been much more effective had there been another expert presenting the potential pitfalls of examining criminal defendants for this disorder. The psychiatrist in this presentation fell into many of those pits: he presented a videotape of the interview in which he asked probing and leading questions (admitting at one point he had to "dig" for symptoms for 20 minutes before the defendant reported any!), and occasionally referring to the defendant as a "patient" rather than as a defendant---clear evidence of bias. The redeeming feature of the presentation was an overview of case law regarding competency and insanity and MPD.

In 2006 there were 4000 civilly committed sex offenders in the US. In this panel they took maps of several large cities in New York, overlaid a map of schools and school bus stations, then overlaid a map of available housing. Finally, the last overlay was a map of legal exclusion zones---boundaries of areas that were legally "off-limits" to convicted sex offenders. This illustrated, at least in Buffalo, New York, that there was literally no place for a sex offender to legally live within city limits. Then they overlaid a map of reported home addresses of sex offenders: 90% were living in restricted areas. There is increasing evidence to suggest that sex offender registration and living restrictions may increase recidivism.

So that's the second conference day. I also enjoyed the computer committee's presentation, which was a two hour geek-fest off all things tech and forensic. It's something you just have to witness to appreciate, sorry. Lots of cloud-based software for document management and report-writing. Not relevant to most Shrink Rap readers but fun for me.

What I Learned Part I

Regular readers know that every year I tweet and blog from the conference of the American Academy of Psychiatry and Law. This group of forensic psychiatrists consists of about 1800 of the country's practitioners. Topics are quite diverse and sometimes rather unusual. It's a lot of fun. Here's just a small smattering of factoids I picked up yesterday:

• The "sovereign citizen" defense can prompt a competency eval, but is not a delusion. The sovereign citizen movement is a recognized subculture of people who believe the government has no jurisdiction over them.
• Of 200 defendants cleared by DNA, one-fourth had confessed to the crime.
• According to FBI uniform crime reports, between 2001 to 2009 2.2% of police murders took place while responding to calls involving a mentally ill person.
• The collection and selling of serial killer memorabilia is also a venue for potential fraud.
• President Peter Ash gave an interesting and useful Presidential address about juvenile violent offenders. Persistent juvenile offenders tend to become more impulsive with age, not less. They commit an average of 30 to 70 previous offenses before they are caught for the index violent offense. They differ from adult violent offenders in that they tend to act in groups rather than alone, they commit impulsive rather than planned violence, and their criminal activities tend to be more diverse than adults. There is a .3 correlation between juvenile psychopathy scores and later adult psychopathy, but this only accounts for ten percent of the variance. Translation: most violent juvenile offenders do not become violent adults. Nobody knows for sure why.
• There was frequent discussion of the hazards and pitfalls of involvement in social media, including discussion about using it to impeach or undermine witness credibility. So far though, when questioned nobody had actually seen this happen to an expert witness. Concern seems to be out of proportion to reality.

HIGHLIGHT OF THE DAY:

My favorite part of this first conference day was the luncheon speech by Pete Earley. Mr. Earley is a former Washington Post report and New York Times bestselling author who's son has a serious mental illness. His book Crazy is required reading in my training program. The book is a description of life inside of one state's broken forensic mental health system. He is passionate and compassionate, and a vigorous and outspoken advocate. The audience was clearly captivated by what he had to say, and at sometimes it was frankly hard not to stand up and shout 'amen'! when he made his points. (Take home quotes for me: "Never give up hope! People get better!" and "A single person can change the system.") I was thrilled to finally meet this very warm man whom I admire. And I'm not just saying this because he wrote a blurb for our book!

SUB-HIGHLIGHT:

I attended a presentation about psychiatrists in the media. The panel presented an interesting categorization of activities: psychiatrist as scientist (presenting and interpreting studies), educator, storyteller, celebrity commentator and curbside therapist. I was surprised and flattered to see the home page of Shrink Rap, and the cover of the book, as an example of "psychiatrist as educator" in the media. I'm glad to see we seem to be accomplishing something helpful.


So that's the first day. You can follow me on Twitter (see the sidebar). If you're here at the conference and want to #OccupyAAPL, drop me a note!

What I Learned Part III

• More on social media and medicine today. One survey of a surgery department showed half of residents and faculty had public Facebook accounts and a third posted professional information.
• People are using "mindfulness" therapy to treat sex offenders. No studies on efficacy.
• Offenders with bipolar and psychotic disorders are twice as likely to have more than two additional arrests than non- SMI offenders.
• Some criminal defendants try to claim that the government is a corporation, and that they should be tried under contract law rather than criminal law. This is sometimes called a "straw man defense" and may prompt judges to request a competency assessment.
• Defendants who graduate from mental health courts demonstrate improved life circumstnaces with regard to housing, quality of life, symptoms and compliance. Some studies have shown mental health courts to result in improvement for as many as 78% of defendants.
• Court ordered custody evaluators are more likely to recommend paternal custody if the mother is poor or has a history of psychiatric admissions. They are more likely to recommend maternal custody if the father has a history of arrests.
• No suicide prediction tool has a predictive validity greater than 3%.
• Forty percent of patients given opioids for non-cancer pain misuse their meds, 5% become addicted.
• In the UK people with ASPD may be subject to multiagency public protection agreements, sharing information between government agencies.

Coming up tomorrow:
      Correctional risk management and the forensic sciences sampler. Good luck to everyone without power in the snow!

Whether or not they work, they're getting cheaper.

Over on Thought Broadcast, Steve Balt has a nice, disillusioned post about whether clinical psychopharmacology is a pseudoscience.    By the end of the post, I was ready to take down my shingle and go home.  I liked Steve's graphic so much (the little pill bottle guy juggling those mood stabilizers) that I stole it.


On another pharm note,  there are several popular medications that have recently gone off-patent or will soon go off-patent, allowing for more competitive pricing as generics become available.  Among them, several big-buck psychiatric medications, including Lexapro, Seroquel, Zyprexa, and Concerta. 

Happy Halloween!

For today's Halloween post I thought I'd share a bit about the forensic aspects of haunted houses. I didn't think there was such a topic until I stumbled over a law review article by Daniel Warner entitled, "Caveat spiritus: a jurisprudential reflection upon the law of haunted houses and ghosts." [28 Val. U.L. Rev. 207].

For the purposes of the law, haunted houses are a kind of property problem known as a "psychologically impacted property." According to Warner, this is real estate tainted with troubled pasts: murders, felonies or suicides. The question is, when you have a house like this are you required to disclose the past to the buyer?

According to the 1983 California case Reed v King, you do. This apparently was the first case addressing the issue. A buyer tried to get out of a house deal after she found out that a woman and her four children had been murdered there ten years before. The court agreed that she had a point because the seller failed to disclose this. After this many states passed laws protecting sellers and their agents from claims over "psychologically impacted property." The problem being, of course, that things like poltergeists and other creatures can't be detected in your typical home inspection.

Then again in 1991, a man bought a house in New York and later found out the previous owner had failed to disclose the presence of a ghost, something well-known in the community. The house was even featured regularly on neighborhood ghost tours. The buyer's wife was very uncomfortable with this even though the seller reassured them after the fact that the ghost was friendly. The court ruled in the buyer's favor, stating that even though the house wasn't haunted 'in fact', the judge decided it was haunted as a matter of law. (The news story about it can be read here.)

So who ya gonna call? According to Mary Pope-Handy, licensed realtor specializing in haunted property, the first person to call is a spiritual professional who may be able to convince the "discarnate" to move on. Unless, of course, you bought the house because you knew it came with a ghost.

How Does Siri Help the Mental Health Clinician?

Next week,  it will be my turn to write our article for the Clinical Psychiatry News website.  Over there, we try to have our writing more specifically aimed at an audience of psychiatrists.  I'm going to be writing an article on Siri and the Psychiatrist....in honor of my new iPhone 4s and the "personal assistant" function named Siri.  Okay, I'm obsessed.  Everyday, I find new things it can help me with.  Today, I asked it, "What's the meaning of life."  What, you don't ask your cell phone the finer existential questions?  Siri answered, "All available evidence suggests chocolate."  Wow!  How old is Liza Minelli?  65 years, 7 months, 20 days.  Calculate a tip? No problem.  Convert Celius to Fahrenheit?  A cinch.  And she takes dictation.  "Siri, please text Pt A 'Your lab results are fine.'"  "Siri, please email Jesse, 'Will you write a new guest post for Shrink Rap?' "  Okay, Siri flubs on this....I can't get her to learn that it's Shrink Rap and not Wrap.  I downloaded a Google Documents App so I can dictate....patient notes, my memoir, a few novels, a Shrink Rap post here and there, To Do lists for Roy....  I think I'm set.


So, I'd like your help.  What useful things are you doing with Siri?  How has your iPhone made life as a clinician better? 

Is it Ever Okay to Lie?

We've been having a great discussion over on the post Tell Me.... An Ethical Dilemma.  The post talks about a young man who wants to know if he can check "no" to a question about whether he has a psychiatric disorder if his illness is not relevant to the situation.  The comments have been fascinating -- do read them-- and very thought-provoking.


One reader asked, " If a patient asked if they were boring you, and they were, would you say yes?"

This is a great question, and of course the right thing to do is to explore with the patient what meaning the concern has to him.  But is that all?  I'm not very good at doing the old psychoanalyst thing of deflecting all questions, and mostly I do answer questions when they are asked of me.  This can present a really sticky situation because one can not think of any clinical scenario in which it would be therapeutic to have a therapist tell a patient, 'Yes, you're boring, OMG are you boring,' or 'No, in fact, I don't like you.'  And not answering could be viewed as negative response by the patient --if you liked me, you'd tell me, so clearly you don't like me.  So if the exploration of the question doesn't take care of the issue, and the patient continues to ask, what's a shrink to do?

I'm not in favor of lying to patients, therapy is about having an honest relationship, but our readers have given some great examples.  If a gunman asks for your money, is it okay to lie and say you have none?  Is it okay to lie about whether you've been the victim of sexual abuse on a job application (one reader saw this!).  Just because someone asks, do you need to answer truthfully?  Of course, you can be truthful and say you don't plan to answer that question, but so many times, the assumption is that the answer must be Yes because if not, you'd have nothing to hide.


Psychiatrists don't owe it to their patients to be totally transparent.  Shrinks have the right to their privacy, and professional boundaries dictate that it's wrong to share your problems with your patients (even if they ask). 


That being said, it still can feel very uncomfortable on the shrink side of a couch when a boring patient asks if they are boring.  What would you say?