Shrink Rap

Send Them Away

2012-02-14T06:58:00.001-05:00

I saw this story on my twitter feed, about a jail sheriff in Ohio who has instituted a policy to refuse to accept any detainees who are violent due to a mental illness. Some people are saying this is a great policy because it will keep people with psychiatric disorders from getting locked up. The sheriff was quick to add though that diverting people out to an emergency room was not an alternative to incarceration. Rather, it was a means of providing immediate care and stabilization to people who might need it.

What lead to this new policy? The article mentioned that budget cutbacks at the jail lead to a decrease in psychiatric coverage, from full time to less than part time. There was also an incident at the jail in which an inmate on the psychiatric infirmary died while struggling with correctional officers. (No details were mentioned about this incident, although some officers were criminally charged.)

I read this story with mixed emotions. On the one hand, I appreciated the need for emergency medical care for some newly arrested prisoners. On the other hand, I had a visceral response to the sheriff's statement: "We're not going to be a dumping ground for these people," said the sheriff. Apparently, he equates seriously mentally ill people with trash. That's the issue I have with this policy. It's not really about getting people the help they need, it's about NIMBY-ism (Not In My Back Yard), a way to turf the treatment of the seriously ill off on someone else. So the jail doesn't want to accept violent mentally ill people, and hospitals don't want to admit psychiatric patients with histories of violence. It seems that the most ill folks are destined to sift down through the institutional bureaucracies until they pool into some environmental equivalent of a Thunderdome.

While the sheriff may be reacting to a budget cut, remember that legislatures don't dictate line-item cost cutting. That's up to the facility administration. So when the sheriff sat down with his new reduced budget, what made him cut the psychiatric hours? Do you think there may be some problem with priorities here?

In my experience people spend too much time arguing over who belongs where. People with mental illness require the right treatment, at the right time, regardless of their physical location. The real solution is to have adequate mental health staff in place and to have custody staff trained to work with them. The facility needs to have policies in place to give emergency medication, adequate safe and humane housing and staff skilled in verbal de-escalation, not to mention adequate mental health coverage. This particular jail has hired an outside consultant who will undoubtedly consider and review all these things. The main point of my post being: The solution to a health care problem should never be to get rid of the patient.

But let's assume for the moment he's acting with good intentions and walk this policy through it's logical outcomes. The biggest challenge---and this is not a small barrier---is that custody will not know when violence is due to mental illness. Even clinicians can have trouble telling if someone is drunk or high on crack or psychotic or just really really pissed.

I'd like to invite our readers to participate in a little practical exercise. Read these scenarios and tell me what you think. Although these are clinical questions you don't have to be a clinician to answer. I'd like to give the general public a chance to think like a forensic doctor.

Clinical Scenario:

You are a forensic psychiatrist working full time in a medium-sized local detention center (a jail). Each of the following patients are brought to you on the same day, and you have to make the call to send the patient out to an emergency room for further evaluation and treatment or keep them in the facility. Remember that none of them have been booked or formally charged yet (they are so 'out of it' that they are brought directly to you rather than getting charged first). If you send them to an emergency room you will get a basic set of lab work done but no further workup is guaranteed. There is also the chance that the arresting officer may decide not to press charges after all, so that he can drop the patient off in the emergency room and get back to the streets. On the other hand, if you keep the patient in the detention center you run the risk of missing a serious physical condition that could leave the patient dead in his cell overnight. Here we go:

Hypothetical Patients:

Patient A: Patient A is brought to the jail by the police covered in blood. He is thought disordered, incoherent and talking about angels and demons. He believes he is in heaven and thinks that satellites have been tracking his movements throughout the city. He is homeless and has no known family or friends. This is his tenth incarceration in five years and his presentation today is consistent with all the other times that he has been locked up. From previous jail treatment records you know that he responds quickly to low doses of medication and will require only a week or ten days of admission to the jail infirmary. When well he has a good relationship with you and always reminds staff when his medication order is about to expire. Even now, he knows who you are and appears significantly relieved to know you are there to start his treatment promptly. The arresting officers, who don't know any of this, warn you as you escort him into your office (in a waist chain and handcuffs), "Careful doc, you don't want to know what he just did to his mother." All of Patient A's previous incarcerations were for non-violent offenses like drug possession and minor thefts.

Patient B: Patient B is brought to the jail by the police covered in blood. He smells of alcohol and has an open bleeding gash on the back of his head. The arresting officer tells you that this is the third time in two months he has arrested Patient B for public intoxication and misdemeanor assault. You have never met Patient B before and have no old records. Patient B is disoriented, hallucinating and talking about angels and demons. As the arresting officer escorts him into your office (in a waist chain and handcuffs), he warns you, "Careful doc, you don't want to know what he just did to the other guy."

Patient C: Patient C is brought to the jail by the police covered in blood. He is angry, swearing and wrestling with both the police and the correctional officers in the booking area. You are unable to get close enough to him to ask questions and when asked questions by the booking officer he responds only with profanity. He has no obvious open wounds or signs of trauma. The arresting officers don't need to warn you about anything. You know enough to stand waaaay back. The only thing you know about him is his reported name, which may or may not be an alias. The officers know him only by his street name, "Woo Woo." He isn't cooperative enough to verify his identity through fingerprints so you can find no old records.

Question:

Which of these patients would you send out to an emergency room from the jail, and which would you keep and treat in house? Why? Discuss.

(This topic is a classic problem in forensic work. It was the subject of one of my earliest blog posts entitled Hot Potatoes.)

When the Kids Grow Up on Meds

2012-02-13T15:43:00.000-05:00

Check out Kaitlin Bell Barnett's blog over on Psych Central. She's a young journalist who has a book coming out called Dosed: The Medication Generation Grows Up. Kaitlin interviewed people who've been on medication since they were children/teens and gets their perspectives. I'm looking forward to reading this one--- it's a really important topic because we know so little about long term treatment of people with developing brains. She got funding on Kickstarter.com and you can watch her talk about her book on the video above.

This Week In The News

2012-02-10T18:27:00.001-05:00

There are a lot of stories in the news lately that have a forensic connection: the disgruntled noncustodial father who blew up his house (and kids), Madonna's stalker who eloped from a psychiatric hospital, a recent legal decision out of Georgia about assisted suicide, and an inmate with gender identity disorder who may be the first to get a state-sponsored sex change operation.

Where to begin, where to begin?

The Georgia decision has personal relevance since it means one of our retired local doctors won't face murder charges for offering advice and encouragement from a distance to someone who died of suicide there. The Georgia Supreme Court decided that the law banning suicide in that state was unconstitutional since it barred mere conversation about the issue separate from any act of aiding a suicide. As such, it was an unlawful infringement on free speech. It's hard to believe that it's been five years already since the first time I've blogged about this topic and fifteen years since the US Supreme Court said it was OK to ban it. Over half the country has laws against it now, but I don't know how many, if any, could be at risk because of the issue with the Georgia statute.

The story about the inmate with gender identity disorder (found thanks to my friend Lorry Schoenly's twitter feed---thanks Lorry! please follow her) also interests me because it's an emerging issue in the treatment rights of prisoners. Specifically, prisoners with gender identity disorder. We've talked about gender identity disorder before on podcasts number 20 and 21 (which included an interview with Dr. Chris Kraft about evaluation and treatment), respectively. I blogged about the history of right to treatment for prisoners here, but there's been one significant change since that 2006 blog post: courts have decided that gender identity disorder does constitute a serious mental disorder which requires treatment. What the courts are arguing about now is whether that right to treatment includes sex change operations. The state of Wisconsin passed a law to ban use of health care funds for this, but that law was overturned as unconstitutional. Prisons are required to continue hormone therapy if it was being prescribed prior to incarceration, though.

Separate from the issue of treatment, GID prisoners don't have a right to dress in opposite sex clothing or to have access to makeup. They don't have a right to be housed in a facility consistent with their gender identity. (Female prisoners sued, and won, cases alleging invasion of privacy when male-to-female GID inmates were housed in a female correctional facility.)

So that's where we are on the GID inmate front. Regarding the Madonna stalker, well, I have some personal experiences with psychotic stalkers but since I don't blog about specific patients that story will go untold.

That leaves the child murder story. Ugh. No thanks. I've seen these cases, they're awful, I'd rather not dwell on them. I'm taking a personal pass.

The Cat Lady Really Is Crazy

2012-02-09T06:09:00.004-05:00

In the March issue of Atlantic magazine there is a must-read story entitled "How Your Cat is Making You Crazy", an interview with neuroscience researcher Jaroslav Flegr. Flegr has been studying the effects of the parasite toxoplasma gondii upon humans. Toxoplasmosis is a parasite endemic to outdoor cats, and the reason why pregnant women are always counseled to avoid the litter box.

I had heard about this line of research before through casual reading, but until now I hadn't realized how strong some of the data actually were or the more subtle and far-reaching effects infection with toxo could have.

Flegr became curious about toxo after incidentally discovering he carried the parasite himself. He wondered if infection with toxo could explain some of his own quirks, specifically his lack of fear and irrational calmness in the face of danger. He knew that in rats toxoplasmosis caused confrontational and overtly dangerous behavior: a rat with toxo will completely lose it's natural fear of cats and will seek out interactions with them.

So he set out to study toxoplasmosis infected people. He discovered that there were subtle but significant differences in the personalities of people who carried the parasite, but the differences were based upon gender. Infected men were cautious and suspicious, socially withdrawn sloppy dressers. Women with toxo were more extroverted, meticulous dressers. Infected humans as a group were also more than two and a half times more likely to get into car accidents---a difference that might be due to both fearlessness and slower reaction times seen in infected people.

Then there was the relationship to psychiatric disorders, the aspect I had already read about. Some neuroimaging studies have shown that people with schizophrenia who show reduced grey matter volume are almost all also positive for toxoplasmosis. This is particularly striking given that toxoplasmosis has two genes which can increase the production of dopamine.

So now when I read articles purporting that psych meds shrink the brain I'll know what question to ask first: "Did they control for the cat?"

A Dangerous Method

2012-02-06T21:02:00.000-05:00

We are taking a break from our normal forensic programming to bring you this guest post from Jesse, a review of the film "A Dangerous Method." ---Clink

Another psychiatrist and I went with our spouses. We all hated it. There were at least three levels on which I considered the film, the first being whether it in fact is a good film, the second relating to what it shows about Freud, Jung, and the birth of psychoanalysis, and the third what it shows about a psychiatrist getting involved with his patient.

A Dangerous Method purports to show Jung, the protagonist, treating a young (and of course beautiful, played by Keira Knightly) Russian Jewish woman named Sabina Spielrein, who was brought to his clinic for treatment of her hysteria. It is quite obvious from the outset that he will fall in love with her, and we are not disappointed, but the predictability and lack of drama in the film are striking. Spielrein gets better and wants to become a physician and analyst herself, which she does (historically, her most famous analysand was Jean Piaget).

We see a little of Freud, stiff and priggish, but quite adamant on maintaining the scientific stature of psychoanalysis and opposed to Jung’s efforts to bring in parapsychology. It is hard to imagine a less sympathetic picture of Jung, and as one who knows relatively little about him I can just say that I hope this film’s portrayal is a strong dramatization: unfeeling, narcissistic, and breaking every rule that has been standard in our field since its inception.

Sabina has been abused by her father by being beaten, which she acknowledges led to sexual arousal. Her symptoms remit as she became able to talk about it. Of course the very worst thing for this woman would be to reproduce that trauma with her psychiatrist, but that is exactly what Jung repeatedly does. The director switches (again quite predictably) between scenes of Sabina being beaten by Jung prior to sex to scenes of Jung’s beautiful and virginally white-clad wife, loyal and forgiving, who tells Jung haltingly that she disappointed him by having given birth to a girl, but will do better next time.

Of course Sabina falls in love with him. You do understand that it is transference. But he soaks it up and wallows in it. For a patient who has been sexually abused and beaten by her father everything Jung does is the worst it could be.

No viewer has any sympathy for him. He is without feeling except for himself. No guilt. No regrets.

Now, if the film really taught us something about psychoanalysis! But it doesn’t. It uses the language but throws off profoundly important concepts with the ease of a ten year old telling you that E = mc2, and with equivalent understanding. Spielrein herself made some important contributions, and Jung was one of the most famous psychologists in the world, but how he got that distinction (rather than ostracism and shame) is anyone’s guess.

So the more you know about psychoanalysis and good drama the more you will hate this film. The more you understand that a patient having a sexual relationship (and even more a perverted one) with a psychiatrist causes profound and lasting damage, the more you will feel that a film that makes the relationship appear harmless is itself causing serious harm.

More Forensic Stuff

2012-02-05T09:26:00.001-05:00

I'm going to apologize to regular readers for missing your usual Shrink Rap fare. This blog isn't usually this heavy into forensic topics but since Dinah is on hiatus, I'm commandeering the blog to talk about my own interests.

I wanted to address some ideas Sunny brought up in my last post. Her comment was: "...I can't figure out why it is that when a psychotic person commits a crime, that "they" send the person to jail to take psych drugs so that they can become "normal" to stand trial. Weren't they mentally impaired at the time of the incident? Why would we, as a society, not consider the state that person was in at the time of the crime? I wonder how those people feel, when they "wake up" from a psychosis to find that they killed people. It must be awful."

There's a lot to talk about here. The first issue is why people have to become 'normal' to stand trial. This is something that is required by the American constitution. The Sixth Amendment gives every defendant the right to call and confront accusers. While defendants can voluntarily give up their right to be present at trial, they can't otherwise be tried in absentia. If someone is too mentally ill to understand what's going on in the courtroom, that's considered an absence (physically present, but mentally 'in absentia'.) This is the origin of the requirement for competency to stand trial.

The state---or more properly, the defense---does consider the mental state of the person at the time of the offense. This is done through a category of defenses known as 'mens rea' defenses---criminal defenses based upon some aberration of mental functioning. There are a lot of them: extreme emotional disturbance, heat of passion, intoxication and insanity. Mens rea defenses don't generally lead to an acquittal---the person doesn't 'walk'---it just reduces the level of guilt. So, for example, instead of being guilty of first degree murder a defendant may only be guilty of involuntary manslaughter. Exactly what you have to prove to make your case about the mental state will be determined by the law. Each state will have statutory or case law that defines insanity or other various mens rea situations.

The states takes mental state into account at sentencing, too. The defense can introduce all kinds of mitigating information for the judge (or jury, in a death penalty case) to consider.

Regarding how insanity acquittees feel when they 'wake up' and realize what they've done: oh yeah, awful---really awful. Particularly since many insanity acquittees commit offenses against their own families. (See the New York Times article I linked to in my last comment on yesterday's post.) Sometimes you wonder which is worse for them: the symptoms of active psychosis or an awful reality.

You're A Whore

2012-02-04T08:24:00.001-05:00

On my post "The Violent Patient", Anonymous Clinician wrote this comment:

"Frankly, I have little respect for Forensic Psychiatry these days. It is a whore subspecialty until proven otherwise, as it is doing what is financially convenient for the MD and just making general psychiatrists pick up the messes."

The accusation that forensic psychiatrist are 'hired guns' is not a new one. When I was a medical student I did a neurosurgery rotation. Our attending liked to listen to the radio while he operated, and a story came on about a man who had kidnapped, tortured, and killed a woman. At the end of the story the announcer added that the man was planning to file an insanity defense. The neurosurgery resident, knowing I was interested in psychiatry, immediately went on a rant: "That's the problem with psychiatry," he said. "Somebody does something criminal and there's always a psychiatrist somewhere saying he was crazy and shouldn't go to prison. This guy should be locked up for the rest of his life. They should do the same thing to him that he did to that woman."

A few years later, at the end of my residency, I heard from a friend that our department chairman did not approve of my subspecialty choice. "It's too bad she's going into forensics," he had told my friend. Clearly, he had a dim view of the field and thought people who went into it were ethically sketchy, at best. (Ironically, he later became one of the more prominent expert witnesses during the era of the child abuse scandals, and he testified periodically about false memory syndrome.)

Shortly after I began my fellowship, Dr. Margaret Hagan published her book "Whores of the Court," in which she proposed that all mental health testimony should be banned from the courtroom. (Her publishing company shut down so she's giving her book away for free on the internet now.)

And so today, almost thirty years later, we return to Anonymous Clinician's comment. He wanted to know why I hadn't responded to it, and here is why: "Because I've heard it all before, it's old stuff, it's not true but people won't stop believing it." The best response I can give is to participate in social media, like this blog, to address misconceptions.

Here are the common misconceptions about forensic psychiatry:

1. Forensic psychiatrists 'get people off' from their crimes.

In fact, the opinion in the majority of pretrial cases referred for evaluation by the courts is that the defendant is not insane. Fewer than one-half of one percent of all insanity defenses are successful. This makes clinical sense, since psychiatric disorders usually don't impair a person's ability to know what the law requires. And it's not the psychiatrist making the decision about guilt or innocence: that decision is made by a group of average citizens---the jury---or by a judge. Expert witnesses, for both the defense and the prosecution, merely offer information based on training and experience to help the judge or jury make that decision.

2. Forensic psychiatrist will say what they're paid to say.

A good attorney will not hire a 'hired gun.' They are paying a lot of money for a witness who is credible, and a forensic psychiatrist with a reputation for being a 'whore' is not going to go very far with a judge or jury. Being a 'hired gun' is bad for business for the forensic psychiatrist too since a bad reputation cuts pretty far into your referral base.

Also, remember that in many cases the forensic psychiatrist is not retained by a private attorney. Many forensic psychiatrists are employed by state health departments. They are salaried employees, not private practitioners. As such, their income is independent of the opinions they form.

3. Forensic psychiatrists aren't doing 'real' psychiatry.

In other words, they're not clinicians. Ah, so untrue. Most forensic psychiatrists will tell you that it's important to retain at least a part time private practice because it's too demanding to have a 100% evaluation-oriented practice. Some forensic psychiatrists don't do evaluations at all, but devote all their time to providing clinical care to patients in correctional facilities or secure hospitals. Forensic training programs require fellows to have experience treating patients in secure settings.

The post is getting a bit long so I'll stop now. Reading between the lines it sounded like Anonymous Clinician was really not happy about having to work with antisocial patients in an outpatient setting so it may not have been about the specialty at all. But there's my response.

(Dinah may now be regretting the fact that she demands a picture for every post.)

Ketamine, Special K, and Depression

2012-02-03T08:00:00.014-05:00

I just wrote a post over on Clinical Psychiatry News about the experimental use of ketamine (aka, rave drug "Special K") for instant relief of depression and suicidal ideation.

Please go over there to read it (link above), and feel free to comment there (sorry, registration is required but it's free) or here. I'd like to hear about providers who have used ketamine for their patients and from people who themselves have used it for depression.

Edit: find a list of clinical trials using ketamine for depression on clinicaltrials.gov.

The Violent Patient

2012-02-02T22:12:00.002-05:00

On the New York Time's Well blog recently, nurse Theresa Brown wrote a piece entitled "Feeling Strain When Violent Patients Need Care," in which she talked about caring for a very threatening, potentially dangerous patient suffering from cancer. This patient, a large 300 pound man, had a reputation for causing havoc in the hospital. He had been banned from one ward for tearing a light fixture off the wall and fighting with hospital security. He had "slugged" a family member at the nursing station and threatened to kill a nurse. In spite of all this, he apparently was not in custody at the time that Ms. Brown was caring for him, which meant that he was not a prisoner in shackles and there was no dedicated law enforcement professional watching over the situation. Understandably, Ms. Brown was afraid.

What some people might not appreciate or been aware of, was that she was also embarrassed about being afraid. Working in the health care field, and in nursing in particular, meant that one could be exposed to volatile situations at any time. Being a professional meant being able to stay calm and poised enough to manage these situations, and this is where the author of this piece felt lacking. She felt she should have been tougher, more unflappable, or somehow invincible to this very concerning patient's intimidating demeanor. Ultimately she was replaced on the case by a male nurse. We never find out what happened to the patient, whether he actually did commit acts of violence during that admission, or whether he calmed down with the male nurse and cooperated with the care he needed. We also don't come to any resolution about what a health care professional should do in a situation like this. This is not a question the narrative was meant to answer, apparently.

As always in story like this, the most interesting part to me were the comments that followed. Over the next two days nearly one hundred people wrote in, mostly nurses and doctors and other health care professionals, to talk about the multiple incidents in which they were bitten, scratched, spat upon, cursed, hit and kicked in the emergency room, on the psychiatric unit, and in the intensive care unit. Half way through the comments I found myself wondering what the incidence of post-traumatic stress disorder must be among health care professionals after a few years of routine work. (I don't know the answer to that question.)

I was also impressed by the range of thoughtfulness that some commenters brought to the situation. Some quickly speculated that the patient might have been a veteran or someone equally traumatized, who would naturally have responded with aggression when startled awake in the middle of the night by a stranger. Others speculated that he might have been having an unexpected reaction to a medication, or been in the midst of a delirium. Some suggested that a CT scan should have been done to make sure his impulsivity and temper weren't due to a malignant brain metastasis. Clearly, these health care professional readers were setting aside their own personal experiences to consider the cause of the patient's emotional reaction and behavior. This was heartening to me.

Other comments were less sympathetic, implying that hospitals should be more liberal in their use of physical and chemical restraints and that assaultive and threatening patients should be prosecuted consistently.

I felt rather fortunate after reading this piece. I've worked with patients known for this kind of violence, but I've been comfortable doing so knowing that safety and security were a necessary and essential condition to providing treatment. I've always felt safer in most correctional facilities I've worked in than in some more traditional clinical settings. Even so, I rarely have had to deal with patients who were so angry or potentially dangerous that I wasn't sure I could treat them even in the correctional setting. That's not good because in most cases there is no one else to turn the patient's care over to when you're the only shrink in the building. This is how I've managed to handle it:

If the patient starts the appointment calmly but escalates during the interview, the first thing I do is slow down. I want time to listen, to think, to make sure the patient knows that I'm hearing him and am concerned about what he's saying. This also helps me listen better. I set my pen down and stop taking notes. I look at the patient. I make sure he knows he has my full attention. If he allows me, I will ask questions to get more information or to clarify something he has said. I repeat what he's told me, and ask him if I am understanding him. If and when he says 'yes', things chill out immediately and we negotiate a treatment plan.

If this doesn't help, or if I start to feel I can't listen safely, I tell the patient I feel uncomfortable or worried. It's not waving a red flag in front of a bull to admit that you're scared. You'd be surprised how many temperamental men (I only treat male prisoners) have no awareness whatsoever that they are talking way too loud or gesturing too broadly or behaving in a way that attracts attention. The nearest correctional officer usually notices first. If I see an officer glancing in to check on me that gives me a nice opportunity to point out to the patient that his behavior is arousing the concern of custody. That always works.

I'm surprised how often an angry inmate will suddenly pull himself together and calm down once you tell him you're scared. Some of them are quick to apologize, or emphasize that---in spite of what they might have done in the past---they have never laid hands on a woman.

Lastly, I know when to recognize when I need to take a break. If I find myself wanting to cut the patient off or getting annoyed---too annoyed to listen---I know it's time to call it a day and try again another time. These are the times when mistakes get made. I can ask the patient if we can take a break and come back to the discussion later in the clinic session, or on another day. I explain that things have gotten heated and I really want to make sure I'm taking the time to think about his care.

If none of this works, I still keep trying. I will make sure I have any necessary security in place, and explain to the patient why it's needed. If someone is available, I may ask another health care professional to sit in the room with me. And make sure an officer is outside the door. In extreme cases, it might be necessary to put the person in handcuffs and a waist chain for the appointment.

Hospitals aren't used to doing any of this, or can't. But when 15% of all US nonfatal on the job injuries take place in health care settings, through patient assaults on staff, it's time to take de-escalation training seriously.

Seeing Alzheimer's Through Art

2012-02-01T00:13:00.003-05:00

William Utermohlen is an artist who died in 2007, twelve years after being diagnosed with Alzheimer's dementia in 1995. His story is discussed in this article in Urban Times. The art that he created during his descent into dementia very graphically tells the tale of his disease.

1996

1997

1998

1999

2000

'All right,' said the Cat; and this time it vanished quite slowly, beginning with the end of the tail, and ending with the grin, which remained some time after the rest of it had gone.

'Well! I've often seen a cat without a grin,' thought Alice; 'but a grin without a cat! It's the most curious thing I ever saw in my life!'

~Lewis Carroll, from Alice's Adventures in Wonderland

[sorry, accidentally had Comments turned off... fixed it]

Shrink Rap has Become Part of the Problem

2012-01-30T15:04:00.001-05:00

I'm taking a break from Shrink Rap for a while and leaving the blog to ClinkShrink and Roy. As I mentioned in my post on "A Matter of Perspective," sometimes people come to an impasse where they simply can't hear what the other has to say in the way that it was intended, and on certain topics, I think I've hit that place with a handful of our commenters. I feel unhappy when I try to express myself and my words get twisted and distorted so that meanings and intentions that are attributed to them are far from what I ever meant to convey. I understand that some commenters feel the same way when they try to get me to hear their points of view, and so I believe we are at that impasse of irreconcilable differences.

At moments, the comments over the past few weeks have been outright mean. There is a respectful way to disagree-- one that has a chance of getting heard-- but some of this has turned into name-calling. As Rob says, I could use a thicker skin when it comes to blog comments. I have been struggling over the past couple of weeks because I write something, it gets shot back at me as something I never dreamed I was saying, and I've been left to ask myself why I want to write for readers who are so angry with me? If they don't like what I have to say, why do they read my blog? If they have a better ideas, why don't they write their own blogs? It's as if Shrink Rap has become a magnet for those who've had bad experiences with psychiatry --- and you know, that's always been fine, we've learned a tremendous amount from our readers-- but lately I feel as if we're not just a forum to allow open conversation on the good, the bad, and the ugly about psychiatry-- but that we've become punching bags. This is not why I've decided to take a break, but it started to move me there.

I spoke with a friend last night who mentioned she's been following what's happening on Shrink Rap. She wanted to know, "What's wrong with those people?"   Other real-life (as opposed to blog life) friends comment that readers won't be happy until I declare that involuntary hospitalization is absolutely the same as Nazi concentration camps without qualification, and I've had other real-life folks contend that I'm catering to the Axis II's (not my words).

I love Shrink Rap, but part of it's mission is to explain psychiatry and to de-stigmatize mental illness and it's treatment. What transpires in our comment section has not been successful lately: if anything some (and please, I mean some) comments fan the flames for the worst stereotypes of patients with psychiatric disorders. They do nothing to further the cause.

A second mission of Shrink Rap is that it gives me a creative outlet, a place to write, a place to vent, a place for thoughtful discourse about things that are important to me. Lately it is a lot of work to watch my every word and very disheartening to still be misunderstood. Just like my day job, you say? No, much harder. My patients come to get well and they understand that I'm in their corner. None of them analyzes the nuances of every word that comes from my mouth. This is good: I talk a lot and sometimes I say impulsive things. My patients are wonderful people, I love working with them, and this is why I love my work enough to want to write about it in my free time.

Many people have commented, or sent me messages and emails, saying they don't understand the hostility and they like Shrink Rap. To all of you: Thank You. I will be back, I just find that it's consuming too much of my thoughts and dampening my mood, so I'm going to step back for a little bit.

I want to say it one last time. If you feel you've been wounded by the psychiatric system, Please Complain. Don't do it in the comment section of a blog-- that doesn't change the world. Try these suggestions:
http://psychiatrist-blog.blogspot.com/2011/06/please-complain.html or start your own blog. If you want to tell me that no one will listen to you because you're a psychiatric patient, I don't believe that.

Please no comments on this post.

Back soon.

Antipsychotic Use for Elderly Nursing Home Residents: OIG Report

2012-01-29T18:10:00.000-05:00

There have been some recent reports about the increasing use of atypical antipsychotics on both ends of the age spectrum. The US GAO (Government Accountability Office) issued a report in December finding higher rates of psychotropic use, including antipsychotics, in foster children compared to nonfoster children (3-4 times higher). Recommendations for increased vigilance and monitoring were made.

In May 2011, the US OIG (Office of the Inspector General) issued a report entitled, "Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents." This report examined claims from a six-month period in 2007, finding that 14% of nursing home residents had at least one claim for an antipsychotic, amounting to over $300 billion. Eighty-three percent of these claims were for off-label conditions (e.g., agitation, insomnia), and 88% were associated with a dementia diagnosis. Atypical antipsychotics carry a warning about using them in elderly patients with dementia due to an increased risk of heart attack and stroke.

So, there was a hearing in November before the Senate Special Committee on Aging about this issue. The hearing itself can be viewed on their website, as well as links to the testimony provided.

This is an important issue, because as our population ages and develops more dementia, the pressure to manage the resulting behavioral problems with pills rather than with patience, understanding, and adaptation. Medications can have a role, but cannot be the only solution and should not be used excessively. Some quotes follow.

I believe that behavior itself is not a disease. Simply put, behavior is communication. In people whose ability to communicate with words is limited (such as patients with dementia), communication tends to be more nonverbal (i.e. behavioral). Our challenge is to figure out what they are trying to say, and if they are in distress, to identify the underlying causes and precipitants. Many of the behaviors that are commonly observed in patients with dementia and that are often labeled as difficult, challenging, or bad, such as agitation, wandering, yelling, inappropriate urination, and hitting are typically reactive, almost reflexive behaviors that occur in response to a perceived threat or other misunderstanding among patients who by the definition of their underlying illness have an impaired ability to understand. ...

Patients with dementia often have trouble comprehending their environment, resulting in misperceptions that are often perceived as threats. In most instances, the key to behavior management in dementia is environmental modification, especially the human environment, which may be as simple as changing our approach and our response in order to prevent and minimize distress. The fundamental basis of health care is caring for others. The fundamental basis of caring is love, acceptance, and respect for persons.

~Jonathan M. Evans, MD, MPH, FACP, CMD
Vice President, AMDA−Dedicated to Long Term Care Medicine

Medications are used often as the first intervention because family members, care givers, nurses and doctors in ALL settings lack information or training regarding alternatives. To merely target this one class of drug as the “problem to be fixed” will have the unintended consequence of increasing the use of other, equally risky medications, such as benzodiazepines, anti‐seizure medications and sedative‐hypnotics, all of which have side effects that include confusion, falls, and risk of death. Furthermore, if the focus is only on the nursing home, we will create barriers to access for care that patients and families desperately need. In some states, such as California where consent rules regarding the use of any psychoactive medications in nursing homes are in place, some nursing homes have declined admissions because of a “history of behavior problems requiring psych meds”, creating real challenges for caregivers and often requiring patients to stay for long periods in the acute care hospital. The solution to this challenge is not a short‐term fix, but rather a two‐fold strategy that involves systemic application of non‐pharmacological behavioral interventions as the first line of treatment, with close monitoring for appropriate and limited use of medications when the non‐pharmacological approaches have not worked.

~Cheryl Phillips, M.D., AGSF
Senior VP Advocacy, LeadingAge

Despite the severity and frequency of these symptoms, there is currently no FDA approved therapy used to treat BPSD [behavioral and psychotic symptoms of dementia]. As a result, many types of medications, including atypical antipsychotics, have been used “off-label” in an attempt to mitigate these symptoms. In 2005, the FDA examined this issue and found that the use of atypical antipsychotics in people with dementia over 12 weeks helped to reduce aggression, but was also associated with increased mortality. ...

The Association recommends training and education on psychosocial interventions for all professional caregivers. Specifically, the Alzheimer’s Association believes “in making the decision to utilize antipsychotic therapy the following should be considered:

 Identify and remove triggers for behavioral and psychotic symptoms of dementia: pain,
under/over stimulation, disruption of routine, infection, change in caregiver, etc;

 Initiate non-pharmacologic alternatives as first-line therapy for control of behaviors;

 Assess severity and consequences of BPSD. Less-severe behaviors with limited
consequences of harm to individual or caregiver are appropriate for non-pharmacologic
therapy, not antipsychotic therapy. However, more severe or “high risk” behaviors such
as frightening hallucinations, delusions or hitting may require addition of antipsychotic
trial;

 Determine overall risk to self or others of BPSD, and discuss with doctor the risks and
benefits with and without antipsychotics. Some behaviors may be so frequent and
escalating that they result in harm to the person with dementia and caregiver that will in
essence limit the life-expectancy and or quality of life of the person with Alzheimer’s
disease; and

 Accept that this is a short-term intervention that must be regularly re-evaluated with your
health care professional for appropriate time of cessation.”

~Tom Hlavacek
Executive Director, Alzheimer’s Association of Southeast Wisconsin

A Matter of Perspective

2012-01-23T19:15:00.000-05:00

Often, when two people can't get along, it seems like the issue is one of communication. People say things that are ill-phrased, or the person hearing a statement assumes an intention that is not meant to be. Sometimes, a well-worded conversation fixes the problem, often with words such as, "I'm sorry that upset you. I never meant it to come off that way and I meant to say X." A misunderstanding, it happens all the time. I sometimes suggest that people read the book Difficult Conversations by members of the Harvard Negotiation Project. The book talks about the value of feeling heard, and how it is important to understand the intentions of the other party. You can't imagine how often I hear stories about people that sound a little off, and when I ask why someone would say or do those things, I hear theories of how the other party is jealous, or just enjoys watching my patient suffer, or is manipulative, or sometimes the stories have quite complex theories dating back to an event that occurred long ago and doesn't seem that memorable. Now the theories could be right, people are jealous, or manipulative, or sadistic, but often I can think of alternative explanations that would explain the same story, and I do think that it may be valuable to ask someone their intentions when things go wrong.

Sometimes, people hit a place where nothing can be said that is right by either party. There are irreconcilable differences. One person may talk of their heart-wrenching distress and weep their story, while the other hears it as "there he goes again trying to get my attention with his tears," and the crying party feels like their honest and sincere attempts are useless on someone with a hard heart. You can find your own variations on this theme, I'm sure.

I've started to wonder if I have perhaps come to this place with our Shrink Rap commenters. I feel like I say something and the response indicates that my comments were misinterpreted.   I try to clarify, it just gets worse, and our comment streams now end with readers insulting the blog, me (apparently I'm someone's nightmare shrink and jail would be preferable--which leads me to wonder why such a person would read our blog), and my choice of topics to discuss. If I talk about an observation I've made, people get angry because of a scenario they've extrapolated that to, which was never what I meant in the first place. Attempts to clarify seem to be futile. I don't feel heard, and clearly, some of the commenters don't either.

And sometimes I feel like readers don't want a discussion at all. A story is written in, and I often sympathize with the story because our readers write in about very touching, and often tragic, difficulties.   They also sometimes seem to feel that it is the Shrink Rappers' obligation, job, or destiny to right the wrongs they see in psychiatric practice and I do believe we've let these readers down. Sometimes, I feel terribly bad for the person who has been victimized, but I'm also aware that I've heard only one side of the story, and I may talk about what the other side might be. And while I don't believe people should suffer, I do sometimes feel that it's helpful to see other perspectives. It enables a search for a solution to occur with a more thoughtful dialogue. But it also means that I sometimes sound unsympathetic in that my answers are read as "Yes, but..." From my point of view, that's part of the discussion, and if you want to say something and want us to respond with absolute sympathy, having heard half of a story that often demonizes our profession, and you don't want to know how the other side might look at it, then I don't think Shrink Rap is the place to come.   I am not likely to write a post about how psychiatrists are all evil and manipulative control freaks who want only to incarcerate, abuse, and poison their patients. And it's not that I don't believe there may be evil shrinks out there, or stories of abuse, or nasty and disrespectful nurses, and I certainly do believe there are psychiatrists who practice quick, uncaring psychiatry for the sake of a bigger paycheck, but sometimes I want to consider other possible explanations.

Let me give an example from recent posts. I put up an article from USA Today on how involuntary commitment is so unpleasant and that if it were more humane, it might not be so awful. I put it up because I agree with it. People wrote in to talk about the abuses they've suffered, and that is fine, it's what I expected. But several people complained about being searched, and how it was offensive and insulting and given their past histories and diagnosis, this was inappropriate. I understand their pain and humiliation, but what doesn't get mentioned is the perspective of others when things go wrong. The patients are new to the unit, the staff has no idea who is dangerous and who is not, and psych units can be very unpredictable places. Some of the policies are made as reactions to bad things that have happened, and often patients have assaulted other patients, or the staff, and suicide attempts (and completions) are not that uncommon. A patient might be insulted at being searched, but is he also insulted when searching is not done and he's stabbed by another patient who came in with a knife taped to his leg? Wouldn't that lead to the same "unbelievable" cry? And to read our blog, one would think that no psychiatric patient might ever care about the safety of the hospital staff or their right to be concerned about it.   It's not that I don't empathize with commenters' suffering, it's that I'd rather there was just a token nod to why it may be necessary. Why does a four-year-old have to remove and x-ray her flip-flops to get on a plane. Do we really think she's going to blow it up? No, but perhaps we think that if they stopped x-raying children's flip-flops, then a terrorist might then use them as a vehicle for a bomb. Or maybe it's all ridiculous and we should be a little bit more thoughtful about our security procedures.

One commenter was distressed about being strip-searched and made the statement that other hospitals don't all do this. Not my field of expertise, but it does seem to me that if one can say "I understand why it's done, I want you to understand how damaging it is," and then go on to say that other institutions don't do this and propose other, less damaging means of addressing the same issue (?metal detectors, drug dogs, pat downs, body scanners, whatever) perhaps there is some power to this. Maybe you get people looking and they say Wow, the institutions that don't strip search patients actually have a lower violence rate (I don't know this, but we do think it's possible that there would be less violence if patients aren't enraged). But someone is going to read my comments about staff and patients being in danger as meaning that I think it's fine to violently rip people's clothes off them, and for the record, I don't.

Another commenter asked if I do this to my patients, this 'yes, but' thing. Sometimes I do. If a patient is telling me a story about an interaction with another person that sounds unlikely to me, I may ask the patient why he thinks he got the reaction he did. Would it be honest to sit there and listen to something that doesn't sound right without challenging someone to think about it in new ways, or to propose some other possible explanations? Let me give an example from a recent Shrink Rap topic. If a man talks about how his adult son has estranged him and he has no idea why and he presents theories that sound unlikely (my son wants to control me, he's jealous, he always favored his mama, you name it), and I have a sense of what might be part of the issue from other things he's told me, I might ask, "Do you think the fact that you don't approve of his wife and the way that they are raising their children might be making him uncomfortable?" Or I might ask if the son may have found it difficult to get his approval when he was younger, or if how the father used to treat him before he stopped drinking might be a part of this.    But it a patient doesn't want to hear this, if they need me to be all in their court, and if they insist I'm wrong (and after all, I wasn't there, so my theories may well be inferior theories), I back off.   The truth is that no matter how troublesome the patient's behavior is or has been, they are my patient, they are the one I am obliged to help, and sometimes I feel around for the best way to do this. No, I don't always get it right.

I don't know if this helps, but I suspect it will inflame things. Commenters may say I'm getting defensive again, and they'd be right. I read some of the comments and think, "You'd say this in my living room?" Because if you're someone who might behave in this manner, there is no way you'd be invited in to my living room.

Follow Up on Sam and Our Survey

2012-01-21T13:20:00.000-05:00

Remember Sam, the student who applied for a competitive internship and didn't know whether to check yes or no for the question about whether he has a psychiatric disorder? If you forgot the discussion, you can read it here: http://psychiatrist-blog.blogspot.com/2011/11/tell-me-ethical-dilemma.html

I thought I would let you know that Sam checked yes on the box that asked if he had a psychiatric disorder. I thought I would also let you know that Sam was chosen for the competitive internship.
-----------------
Last week we asked readers who have been certified to psychiatric units if they would want to be involuntarily hospitalized again if they became ill and imminently dangerous again. 63 responses, one person hit submit without answering, and here is the final tally:

Summary See complete responses

If you became psychiatrically ill again and presented an imminent danger to yourself or others, would you want to be involuntarily hospitalized again?

Yes		20	32%
No		42	67%

When Adult Children Shun Their Parents

2012-01-19T11:30:00.002-05:00

Over on Shrink Rap News, a post will be going up about my random thoughts about adult children who essentially divorce their parents. In the families I'm talking about (and I know many), these aren't extreme situations--the children did not suffer from abuse, neglect, or deprivation at the hands of their parents. When they were children, the parents tried to be attentive, caring, and to provide for them as best as they could (which was sometimes rather well). The parents likely made mistakes, because parents are not perfect, but the issues are current ones...and often ones the parents themselves can't articulate. In these cases, the adult children have severed ties even though the relationship was close, and they themselves might say they had good childhoods. Why the estrangement? I suppose it's different in each case, and often there are issues with parental divorce, the relationship with the child's spouse, a sense that the parent is too critical, too judgmental, or perhaps too intrusive and controlling. The adult children may feel they are being used or manipulated. I talk about some of my theories, and they may well all be wrong. None of it science, just what I've gathered from listening. If you'd like to read my thoughts, I invite you to surf over to CPN's Shrink Rap News. And, of course, I'd like to hear your story. You can check over there sometime around noon.

If you're interested, I'll also direct you to a website run by someone dear to me: MOTHERRR! -- about rebuilding mother-daughter relationships. While my post talks about estrangement from the vantage point of the parents, this site looks as mother-daughter difficulties from the perspective of the adult child.

The Privileged Patient

2012-01-18T07:44:00.001-05:00

I'm still dwelling on these discussions we've had about the inpatient experience. A number of readers commented that they weren't like other patients on the ward who weren't educated, who used drugs and were in and out of jail. I took that a little personally since those "other" inpatients are my correctional patients. I like working with them and I don't like it when people dismiss them as being "just criminals." I also found it a bit ironic that the people who are quick to claim peer kinship with staff are also quick to disclaim equality with forensic patients. You really can't have it both ways. My offender patients deserve to be taken seriously, treated with respect and given humane care whether you want them in your community or not.

I don't like the idea of framing treatment in terms of who is more 'deserving' of care. I don't think you can put a rating scale on suffering or prioritize trauma. Nevertheless, when it comes to the spectrum and amount of services that are needed my forensic patients are right up there. They may not be very literate, they've got poor social supports as well as mental health and addiction problems. Oh, and chronic medical problems that go untreated because they have no insurance. They're facing an uphill battle just to reach a "normal" place in society. For my patients, success means having a place to live, a job, people who care about them, maybe even a car and a girlfriend. That's a lot to have when you're starting at zero. Yet when it comes to apportioning services and access to treatment these are the first folks to get cut.

Some inpatient units do have patients of privilege---people who aren't starting at zero---and these patients really do seem rich (figuratively and literally) in comparison. But forensic patients are increasingly part of our mental health care system. When we talk about making the system better they have to be part of that discussion.

The Opinionater on The Age of Anxiety

2012-01-16T20:23:00.010-05:00

Before I start, two things: 1) if you'd like to hear our interview with Dan Rodricks on WYPR today, go here. 2) If you've ever been forcibly certified to a psychiatric unit and you haven't taken our poll yet, please do so here. And now for our next post:

Over on the New York Times "Opinionator," Daniel Smith has an article called ""It's Still the Age of Anxiety. Or is it?" Smith talks about W.H. Auden's Pulitzer Prize winning1948 poem, The Age of Anxiety, (it's boring, he tells us, as well as 'illusive, allegorical and at times surreal') and he tells us about his own anxiety. Smith writes,

From a sufferer’s perspective, anxiety is always and absolutely personal. It is an experience: a coloration in the way one thinks, feels and acts. It is a petty monster able to work such humdrum tricks as paralyzing you over your salad, convincing you that a choice between blue cheese and vinaigrette is as dire as that between life and death. When you are on intimate terms with something so monumentally subjective, it is hard to think in terms of epochs.

And yet it is undeniable that ours is an age in which an enormous and growing number of people suffer from anxiety. According to the National Institute of Mental Health, anxiety disorders now affect 18 percent of the adult population of the United States, or about 40 million people. By comparison, mood disorders — depression and bipolar illness, primarily — affect 9.5 percent. That makes anxiety the most common psychiatric complaint by a wide margin, and one for which we are increasingly well-medicated. Last spring, the drug research firm IMS Health released its annual report on pharmaceutical use in the United States. The anti-anxiety drug alprazolam — better known by its brand name, Xanax — was the top psychiatric drug on the list, clocking in at 46.3 million prescriptions in 2010.

Just because our anxiety is heavily diagnosed and medicated, however, doesn’t mean that we are more anxious than our forebears. It might simply mean that we are better treated — that we are, as individuals and a culture, more cognizant of the mind’s tendency to spin out of control.

Smith concludes that it's not the world we live in, and that it's perhaps dangerous to make that assumption. He notes, " If you start to believe that anxiety is a foregone conclusion — if you start to believe the hype about the times we live in — then you risk surrendering the battle before it’s begun."

What do you think? Are we more anxious than we used to be? And why is that? Is it the world we live in--now or in 1948? Or is it just our own personal psyches?

Note, the graphic above is from a book by Andrea Tome.

Our Interview with Dan Rodricks on WYPR

2012-01-16T16:14:00.007-05:00

If you missed our interview on Midday with Dan Rodricks, you can still listen by clicking on the Download link, or clicking on the My Three Shrinks icon to the left will open up a browser player in a new window.

Monday January 16, 1 - 2 pm: Everything you could know about psychiatry in a 50-minute hour

What is psychotherapy, how does it work? What is psychoanalysis, and why don't all shrinks practice it? Our guest this hour three Baltimore psychiatrists -- answer questions about how they work with patients. Our guests: Dr. Steven Daviss, chairman of psychiatry at Baltimore Washington Medical Center; Dr. Dinah Miller, in private practice; and Dr. Annette Hanson, a forensic psychiatrist with appointments at the University of Maryland and Johns Hopkins Hospital. They write a blog together and are authors of “Shrink Rap: Three Psychiatrists Explain Their Work,” published by Johns Hopkins University Press.

Download

Midday producer Michael Himowitz says of the book: "This is a remarkable book. I was prepared to endure it, but it turned out to be well-written without being glib pop-psychology, informative without being overly laden with jargon, and surprisingly candid about psychiatry’s failings and problems. They should have named it Shrink 101, because it really covers the basics about navigating the disorganized and confusing world of mental health care."

Involuntary Commitment: Would you do it Again?

2012-01-14T20:14:00.003-05:00

Ah, we're back to an old topic, involuntary hospitalization. Some people say they'd rather die than live through a week in a hospital again. I actually have not ever heard anyone say that about jail. I thought I'd ask if everyone feels that way. If you are very much against the idea, but have not been involuntarily hospitalized yourself, please-please-please, don't take my poll.

Thank you and Go Ravens!

Recent posts on forced treatment:
Jan 9: Forced Treatment: Does it Help? ("make psychiatric care something patients want to get")
Jan 13: I'm Sorry ("I'm sorry that... the mental health system has failed [those who have died due to hiding from 'treatment']")
Jan 14: What We Need (list of 12 things readers are saying they need from the MH system)
Jan 14: Poll: Involuntary Commitment: Would you do it again? (a survey for those who have been committed in the past)

What We Need

2012-01-14T11:14:00.002-05:00

OK, I've gone back through the comments on my last post as well as on Dinah's forced treatment post. I think I've come up with a list of what people have identified as things that need to be added, improved or changed. I'm going to talk to myself in this post, thinking out loud a bit about what each item means to me and how to implement them. Feel free to follow along, add, edit or just ignore me. Like I said, I'm thinking out loud in public.

1. An emergency ear
     Even people on an inpatient unit need a crisis contact. A friend to call, an outside volunteer, better access to visitors like family, or a hospital ombudsmen. Patients may not want to or can't access staff, which is a problem. Purposely or unconsciously, inpatient staff discourage patients from approaching them about problems. Patients feel they have no recourse when they are treated poorly or unprofessionally. Some hospitals use after-the-fact patient satisfaction surveys, but personally I'm reluctant to solve a problem by using a form. There needs to be a neutral mediator or ombudsman who is easily accessible to an inpatient. Perhaps allowing an outpatient therapist to hold sessions during a hospitalization would be helpful. (I know there may be financial and bureaucratic issues related to all the items I'm discussing---for the time being let's ignore that. This phase is just outlining the problems and needed solutions.)

2. Professionalism
This item is closely related to item #1. If this item were fixed then item #1 might not exist. What most people may not know is that medical schools recognize this is an issue and now incorporate assessment of professionalism into every medical student and resident evaluation. National professional organizations are also thinking about ways of building this into ongoing licensure processes by requiring physicians to solicit evalutations from their patients. There are also now loads of online 'rate-your-doctor' sites. This is just for physicians, though. I'm not sure how to go about evaluating professionalism for hospital security staff who put someone into seclusion. The psych aides or techs would likely fall into the nursing department realm, and there's no reason there couldn't be a patient feedback loop for that profession as well.

3. Regret
Ah, this is the tricky one. Some commenters said they wished their doctor would have told them that the doctor felt horribly about having to commit someone. Well, when a patient is in crisis it's really not the time to focus on the doctor's feelings. The point is well taken though that mental health providers should be able to talk to the patient afterward about the experience of involuntary treatment, what it was like (for both parties) and ways to avoid it in the future. See item #4.

4. Outpatient crisis plan
I've seen some nursing admission forms that routinely ask patients on admission what they do when they are feeling angry or upset, and what helps them feel better in times of crisis. This almost never involves social connections though, which commenters here say they want more of. This is related to #11, the ongoing discharge plan. Who is in your social support system? Are they helpful are hurtful? Who can you reach most easily? Have you actually used this support system in the past or are you b.s.-ing to get out of the hospital (honesty is going to have to cut both ways, now!)? Hospital lengths of stay are so short now there is almost no purpose to a trial pass or day pass. The general thinking is that if you're well enough for a day pass you must be well enough for discharge. The generic 'return to emergency room' is far from an ideal crisis plan. Perhaps some temporary ongoing outpatient relationship, similar to what internal medicine does: discharge from hospital, to be seen in inpatient doc's own outpatient clinic within X days, until more permanent or preferred outpatient care is arranged.

5. Decent food
Oy, I am the Shrink Rapper with zero food skills. Either of my co-bloggers will confirm that. Nevertheless, it seems evident that medically appropriate, religious or personal preference diets should be available. This one just doesn't seem that complicated, but I don't question that it's a problem.

6. Clean, comfortable environment
Ditto #5. This is one item where patient satisfaction surveys actually could be useful. If month-by-month discharge surveys are all saying you've got bugs in your bathroom, you've got a problem.

7. More autonomy over medications
Pharmacotherapy is always a balancing act between the level of symptoms a patient can live with versus the burden of side effects that they have to carry. I would throw in this thought as well: the people in your support system have to live with your symptoms, too, so they should also be considered. Can we engage family and friends in this balance? If so, how?

8. Meaningful activities
I get this, totally. It's tough when you have an inpatient unit that contains both patients who are so ill they need help bathing and dressing as well as multiply-graduate degreed professionals. William Styron once called occupational therapy 'organized infantilism.' These individualized treatment plans that every team has to fill out should be made useful in some way, and this is where this item should be addressed. What meaningful activities would an educated, high-functioning professional want to do (or feel up to) doing? Most of the units I've worked on have not served many of this kind of patient so I'm open to suggestions here. You also have to address the question: if you're well enough to do (high functioning activity X), do you really need to be in the hospital? That's the question insurance companies will be asking your doctor.

10. Alternative and complimentary treatments
     People want things to do besides (or in addition to) taking medication. I'm guessing this means things like emphasizing regular activity or exercise, proper diet, decent sleep but also activities like yoga or tai chi, bibliotherapy (journal keeping, poetry or other writing), music therapy, and so forth.

11. Ongoing discharge planning
     I've already covered this a bit, but this would refer to the feeling that people are just dropped outside the door of the unit after discharge with no further contact with the inpatient team. There are already some programs available like day hospitals or partial hospitalization programs, but I don't think this is what people are asking for. I'm thinking more along the lines of returning to the inpatient unit for an "outpatient" visit, if that makes sense, while making the transition to a traditional outpatient practice.

12. Humanize (or de-traumatize) the observation process
     This is the last and toughest point. How do you humanely take someone's clothes away while putting them in physical restraints on continuous observation? I know, some people will say this should never be done but that's just not the world I live in. Some people are dangerous when they get sick. Psychiatrists have to make sure everyone in the unit is safe, in addition to protecting the patient. Making sure everyone is trained to recognize and intervene early is important, to prevent seclusion and restraint. Working with the patient early on to identify coping skills and practice those skills, and make sure people on the unit are trained in verbal de-escalation techniques. This won't obviate the need for seclusion in all situations, but it should help minimize its use.

OK, I've spent a fair amount of time thinking about this post, reading old comments, writing and speculating and I'm running out of steam. More later. The last three or four items are going to be the longest, I think. Dinah and Roy, feel free to jump in with your thoughts. This is the stuff of inpatient interviews.

The Shrink Rappers on Midday with Dan Rodricks: Monday, January 16 @ 1 PM

2012-01-14T06:00:00.003-05:00

Midday with Dan Rodricks

We joined ~~will be joining~~ Dan Rodericks on WYPR, 88.1 FM on Monday from 1 to 2 pm. You can listen to it or download from WYPR. ~~If you're local, please listen. If you're not, live streaming information is on the WYPR website at http://www.wypr.org/listen-live.~~

~~We'll put up a link after the show, and information to call in or email is shown below.~~

Midday is WYPR's daily public affairs program heard from noon-2pm, Monday-Friday. Hosted by longtime Baltimore Sun columnist Dan Rodricks, the program covers a wide-range of issues selected to engage, inform, and entertain the listening audience. Topics range from the latest news, to local and national politics, to social, medical and cultural trends, featuring the best new books and most engaging authors, newsmakers and guests.

Dan has won numerous regional and national journalism awards, and he has frequently been cited as Baltimore's favorite columnist by Baltimore magazine and the City Paper. Previously, Dan was a commentator on WBAL-TV, host of a talk show on WBAL-AM, host of documentaries on Maryland Public Television and, from 1995 to 2000, host of the popular Rodricks For Breakfast show on WMAR-TV. He is the author of two books about Baltimore and lives in the city.

Executive producer: Vanessa Eskridge
Engineer and Director: Tom Welch

I'm Sorry

2012-01-13T06:58:00.001-05:00

Rob wanted to know if I was reading the comments on Dinah's post about involuntary treatment. He thinks that psychiatrists may read these comments, shrug and say, "Well, sometimes it's necessary."

I did read the post, and the comments. I can tell you that the decision to involuntarily admit or treat someone is never a "shrugging" issue. This is something psychiatrists hate to do. I mean, literally hate. We know it's something that can destroy a therapeutic relationship and undermine someone's willingness to seek care in the future. We know that psychiatric units can be horrible places to be and that admission is expensive, humiliating and sometimes traumatic. The decision to seek involuntary treatment is not done lightly or easily. You and some others may feel it should never be done, but I think that's an issue that may never get resolved between us. Maybe someday medicine may develop better ways to diagnose and treat mental illness, or society may evolve and decide that psychiatric patients are worthy of the time and money spent on other suffering people but we're not there yet. We deal with the present, as it stands, with what we've got.

Remember that there are comments that you don't read here. The missing comments. The comments that can't be posted because the suffering people are dead. On behalf of those folks, and the people who care about them, I'm sorry. I'm sorry that psychiatry as a profession and the mental health system failed you. I'm sorry that you had to hide your suffering from your friends and family, or maybe from your doctor, because you thought you had no choice. Clearly, something needs to change.

This is why Dinah posted about the issue and why I'm following up. As a group, we need to figure out better ways of doing things. The Shrink Rappers don't have the answer. We need to hear concrete ideas and suggests. General comments like, "Stop treating me like a child" or "Don't be a jerk" honestly aren't helpful. The commenter who suggested that patients should be allowed to have cell phones on the unit, to call friends or family when in crisis on the unit, now that's the kind of idea we psychiatrists need to hear. The discussion about post-discharge aftercare and the continuity gap is crucial. Please tell us more about that and about what kind of services or support would have been useful and what we need more of. I like the idea that this could also help catch people in early relapse. We need to answer the questions about these services: what, when, where, who and how.

Now let's get started.

Baby's First Laptop

2012-01-11T07:15:00.000-05:00

I just stumbled across this on the Amazon web site and had to post it. People have been writing lately about the effects of technology on kids, but I guess it's not that serious since we're making 'real' technology for babies now. What's next? Baby-safe web sites? Infant chat rooms? Babble blogs? (Oh what, we've got those already...)