My Three Shrinks

December 9, 2007: #37 Poop-Out

# SSRI Poop-out (a.k.a. tachyphylaxis). This is the phenomenon where a drug is working, then seems to wear off or stop working after some period of time. (see also How a Shrink Picks an Antidepressant, Family Intervention Overcomes Poop-Out, and Stassen's article on resilience.) (I also referred to the use of gestures when speaking.) Also discussed placebo response, light therapy, and Dinah's shpiel.# Google Ads. We discuss issues about our minimal use of ads on the blog.# Q&A from Tony. Refer back to Questions for the Doctor.# Clink's Opera Post. Send us your general questions at mythreeshrinksATgmailDOTcom.Go to http://mythreeshrinks.com for show notes with links.

November 11, 2007: New & Improved!

* MacArthur Foundation Grant: Decision-making, substance abuse, and brain abnormalities. Developing guidelines for judges about neuroimaging and brain function.

* On our Shrink Rap blog, Clink blogs about What She Learned (Part 1, Part 2, and Part 3) at her AAPL conference.

* Delirium. Roy discusses delirium, or encephalopathy, what it is and recent findings about longer term damage.

* Shrink-proof containers. Clink brings back a hotel bottle of mouthwash that she could not open.

* Q&A: Gerbil brings up recent study on chocolate lovers.

* Online CBT for Depression. Study finds it helpful for mild-moderate depression. Eliza.

* Telepsychiatry. We just chat about some of the issues.

Send us your general questions at mythreeshrinksATgmailDOTcom.Go to http://mythreeshrinks.com for show notes with links.

October 24, 2007: Dr Anonymous' BlogTalkRadio Show

On Thursday night, October 18, the three shrinks called into Dr A's call-in internet radio show (invited) and we talk about general stuff and answer LIVE questions from the listening audience. Most of the questions seemed to be about Halloween (including favorite candy received at Halloween... I feel another Dinah sidebar poll coming on.)

You can check out Dr A's talk show every Thursday night from 10-11pm ET at blogtalkradio.com/doctoranonymous.

Go to http://mythreeshrinks.com for show notes with links.

October 08, 2007: Just Do It

* Crisis in the Treatment of Incompetence to Proceed to Trial. In the recent Online AAPL Journal, an article by Wortzel about problems with assessing defendants who are not competent to stand trial and restoring them to competence. [hmm, wonder whose topic this one is] At any given time, these people occupy about 10% of our nation's state psychiatric hospital beds. A complicated discussion ensues about who pays for forensic mental health care and how the system results in decreasing access to care for uninsured non-forensic patients. * We respond to a question to the NYT Ethicist column, by Randy Cohen, which you can read here (as well as his answer). [Note: we last saw Randy when he stopped by to respond to a discussion about a previous column of his about suicidal people making wills.] The question involves whether it is okay for a physician, who is a psychiatrist, to prescribe a stimulant (Adderall) to his college kid for the purpose of improving test-taking performance. (We discussed the practice of treating family members in a prior post, My Patient, Myself.) A secondary question involves that kid sharing the medication with a friend. We also discuss the issue of using performance-enhancing amphetamines for non-illnesses, in addition to the potential for a performance-reducing effect due to side effects (which is also taken up on Gawker's Unethicist). (We also ask for help from any DEA agent listeners.) * Clink celebrates her 25th Running Anniversary. She's been just doing it for a quarter century. * Price Transparency for Psychotropic Drugs. Dinah discusses her post about the list of prices for antidepressants. Roy unsuccessfully looks for the prices of these drugs on the Maryland Medicaid website.

Coming up in Podcast #37... SSRI Poop-out (aka tachyphylaxis) and other good stuff. Oh, and here's a pic from my Vegas conference trip. Yummy!Send us your general questions at mythreeshrinksATgmailDOTcom.Go to http://mythreeshrinks.com for show notes with links.

October 05, 2007: Guest Mark Komrad, MD

Last week, we had our guest, Dr. Mark Komrad, join us and begin to discuss the portrayal of psychiatrists in the movies. Mark used to have a live, two-hour, coast-to-coast, nationally syndicated talk radio show, and is a regular guest on NPR. He is also the Ask-a-Doctor on the NAMI site, and also has a book coming out. Mark was a guest blogger back in July, when he posted on Ethics and Continuing Education for the Psychiatrist.This week Mark continues to discuss how Hollywood likes to portray psychiatrists in film. You can find him at www.komrad.yourmd.com. (Unfortunately, Monkey the parakeet gets sidelined in this podcast.)

Topics include:

# Leona Helmsley's dog, Testamentary capacity, and Psychological Autopsies. ClinkShrink discusses how one starts to address the question of competency to being able to make the decsion to leave $12 million to one's dog. Bounty and one's natural heirs.

# Irv Schneider's 3 Psychiatric Archetypes: Doctors Dippy, Darling & Dangerous. These are the three categories of psychiatrists most frequently played in the movies and television.

-DR. DIPPY: Bob Newhart Show; What About Bob? (Richard Dreyfuss); High Anxiety (Mel Brooks); Analyze This (Billy Crystal)

-DR. DARLING: Equus (Richard Burton); The Sopranos (Dr. Melfi); Sixth Sense (Bruce Willis); Good Will Hunting (Robin Williams); Prince of Tides (Barbra Streisand); Ordinary People (Judd Hirsch); K-PAX (Jeff Bridges)

-DR. DANGEROUS: Silence of the Lambs (Anthony Hopkins); Terminator 2: Judgment Day (Dr. Silberman); Dressed to Kill (Michael Caine); Beauty and the Beast (Belle's father)See My Patient, Myself. How we must "neutralize" the negative images of psychiatrists in the media, "like your podcast." How the movie, Lovesick, affected the idea of psychiatrists falling in love with their patients.# Psychiatric Services: Religion and Psychiatry. We have an interesting talk about the role that a physician's religious background may play in the likelihood of referring a patient with complicated grief to clergy versus a psychiatrist. See Roy's upcoming post on Religion and Psychiatry for more info. Briefly:-Psychiatric physicians were more likely to be Jewish or non-religious than nonpsychiatric physicians.-Protestant physicians were twice as likely as other physicians to refer the example patient to clergy rather than a psychiatrist.# Washington Post: Roy briefly mentions his recent post on the final report on the Virginia Tech tragedy and the potential impacts on privacy of health care information, willingness of college students to get help, and liability. Dinah suggests readers go back to look at our prior posts about college mental health, Suicidal Students and Let's Talk About Suicide. This also led to a discussion about outpatient commitment.# Correction: Dinah corrects her reference in Podcast 34 to Reign Over Me. The movie she was actually discussing was The Departed.# Check out NAMI's Ask-the-Doctor column that Mark writes, also his website at www.komrad.yourmd.com.Send us your general questions at mythreeshrinksATgmailDOTcom.Go to http://mythreeshrinks.com for show notes with links.

September 26, 2007: Guest Mark Komrad, MD

This week we have a special guest, Dr. Mark Komrad, who is an old hat at discussing psychiatric issues on broadcast media. Mark had a live, two-hour, coast-to-coast, nationally syndicated talk radio show for about 5 years. He also had a regular gig on Channel 2 with Rudy Miller, and continues to be a regular guest on NPR. Mark is the Ask-a-Doctor on the NAMI site, and also has a book coming out. Mark was a guest blogger in July, when he posted on Ethics and Continuing Education for the Psychiatrist. (And Monkey the parakeet joins in.)

Topics include:

# Prison Tattoo Database. Clink informs us about Maryland's tattoo database. Dr. Komrad talks about Match.com's inclusion of tattoos in their matching database. We also talk a bit about the psychology of getting tattoos, in general.# Q&A: I am a second-year medical student in Canada who is considering psychiatry. I have a few questions that hopefully you haven't already addressed elsewhere.Firstly, do you get many negative responses from other medical professionals and the general public for being psychiatrists. If so, how do you deal with it?Secondly, can you discuss some of the differences you know of in practicing psychiatry in Canada versus the US?# Dr. Komrad discusses how he got into Psychiatry, and the images of Psychiatrists in the movies and in Hollywood. (Mentions Irving Goffman here.) Mark points out that only 3% of Americans have even been to a psychiatrist, and so most people learn about what Psychiatry is about from movies. Movies and shows discussed include The Sopranos, Dark Shadows, Beauty and the Beast, Prince of Tides... more on Podcast #35.# Check out NAMI's Ask-the-Doctor column that Mark writes, also his website at www.komrad.yourmd.com.Send us your general questions at mythreeshrinksATgmailDOTcom.Go to http://mythreeshrinks.com for show notes with links.

September 16, 2007: Inane Banter

Topics include:

* Q&A from Jennifer: "In your relationships with the greater world, do you find that you are more compassionate and understanding when it comes to putting up with the foibles of people since you have a greater understanding of the brain? When you see people in traffic driving like they own the road, do you still simmer and think dark thoughts like the rest of us, or do you think, 'well there goes a person who clearly has issues of narcissism (or whatever), and I just hope he doesn't smash into anyone'? Do you find the inane banter of teenage girls less headache inducing because you know the stage is only one of a thousand they will go through on their way to the grave and Oblivion? If a really religious neighbor keeps bugging you about your lack of faith and tries to nag you into going to church with her, would you just smile and thank your stars that you are free of 'invisible friend' delusions? If any of these scenarios are true, I think I may need to go into psychiatry." We do a decent job of answering these questions. * American Visionary Arts Museum (AVAM). Clink discusses her observations about this Baltimore museum and some critical comments noted about the squelching of creativity by Psychiatry.

* Involuntarily medicating an "incompetent" defendant. Clink discusses a Baltimore Sun story (couldn't find link) about changes in Maryland created by "the Kelly case". It has now become harder to medicate defendants who are not competent to stand trial. * Q&A from Emily: "Have you read the book called 'Crazy: A Father's Search Through America's Mental Health Madness' by Pete Earley? It is about the criminalization of the mentally ill. When I read it, my mind was opened to the phenomenon of mentally ill people who commit crimes while under the 'influence' of their symptoms, and are punished by being imprisoned rather than getting adequate mental health care assistance.

A few questions for you:

-Do you feel that prisoners who require mental health care are able to be receive adequate assistance while locked up?

-How do you feel about mentally ill prisoners? For example, a paranoid schizophrenic who committed acts such as breaking & entering, destruction of private property, etc while hearing voices instructing him to do so, and winds up in prison rather than a psychiatric hospital. Do you treat people in similar circumstances?

-Something else that the book talks about is mentally ill people who are arrested and put in jail, then deemed incompetent to stand trial and sent to psychiatric hospitals until they can be stabilized, then sent back to the jail where they rapidly decline again for a number of reasons before they can stand trial. And the cycle goes on and on.

-So I was wondering how much of this you witness in your daily work. How often do you see people that you think should be in a psychiatric facility instead of a prison? How big of an issue do you think it is, or what do you think should be done differently?" Clink addresses these questions, and also her contact with Pete Earley, and about another book of his, Hothouse, about Leavenworth Prison.Send us your general questions at mythreeshrinksATgmailDOTcom.Go to http://mythreeshrinks.com for show notes with links.

September 2, 2007: Doctor Anonymous on Depression Overdiagnosis

Topics include: * DrA on Skype (not a soundboard). Dinah relished the memory of Podcast #24. Check out DrA's blog, doctoranonymous.blogspot.com. * Is Depression Overdiagnosed? We discuss two point-counterpoint pieces in the August 18 2007 issue of BMJ (British Medical Journal). The YES piece is written by Gordon Parker, who believes there is a trend to turn "sadness" into a medical condition: "The ease of assigning a diagnosis of clinical depression, even of major depression, has rebounded on psychiatry, blunting clarification of causes and treatment specificity." The NO piece is written by Ian Hickie, who argues that despite the benefits of increased rates of diagnosis, many people with depression continue to go unrecognized, untreated, and impaired: "The increased rate of diagnosis has had other benefits, including reduced stigma, removal of structural impediments to employment and health benefits, increased access to life insurance, improved physical health outcomes, reduced secondary alcohol and drug misuse, and wider public understanding of the risks and benefits of coming forward for care."

Find online comments on these articles at BMJ's website here. * Further discussion about the symptoms of major depression, subsyndromal depression, dysthymia, substance abuse, the influence of the pharmaceutical industry, depression screening, access-to-care problems, inpatient bed capacity problems, per capita psychiatrists and psychologists, stigma about mental illness, primary care management of depression, emergency evaluations. * We digress into hot McDonald's coffee, Twinkies, and chocolate.

Also, check out DrA's new talk show at doctoranonymous.com.

Send us your general questions at mythreeshrinksATgmailDOTcom.Go to http://mythreeshrinks.com for show notes with links.

August 20, 2007: Biteproof Gloves

* Q&A: from Midwife with a Knife: Short version: How would you manage an agitated, aggressive patient in your OB/GYN office? [Okay, here's the long version: Let's say I have this patient who's clearly distressed and obviously psychotic (if I can tell, it's pretty obvious) who's caretaker reports that they're seriously considering hurting themselves or others, clearly the patient needs to be sent to the psych ed/crisis center/whatever hospital equivalent for evaluation by an actual mental health provider... So, after the caretaker says to us, "I'm worried about taking her back to the group home, I'm think she's planning to hurt someone there.", and I talk with the patient who says something to the effect of, "I know that woman's planning to take my baby, and I'm going to hurt her before she gets the chance." I make the decision that she needs to be emergently evaluated. I try to talk her into going voluntarily (mostly by saying things like, "You seem pretty upset, I think it might help if you went and talked with the doctors downstairs", she refuses, and security is called to escort her down to the psych ED. Eventually, (I think triggered by the stress of that situation and the chaos of a busy clinic and the security officer's arrival), and in an attempt to leave the room (I happened to be sitting between her and the door), she kind of half tackled/half grabbed/half pushed me (Maybe to push me out of the way? I think she was just trying to leave. I don't think she was really trying to hurt me), the security officer grabbed her, she bit him (although he was wearing biteproof gloves) and she eventually was taken to psych. My question for you guys is, How do you psychiatrists recommend those sorts of situations be handled? So, we answer the question in the podcast. We also speculate about "bite-proof gloves."Oh, and if you want to see a funny but very strange rendition of Zappa's Peaches and Regalia -- with a man using his ungloved but cupped hands as a musical instrument -- then do check out this YOUTUBE VIDEO (turn down your volume first). I could not stop laughing.

Send us your general questions at mythreeshrinksATgmailDOTcom.Go to http://mythreeshrinks.com for show notes with links.

August 17, 2007: Parity Feels Like a Bird

Topics include:

* MENTAL HEALTH INSURANCE PARITY LEGISLATION. 20-minute discussion about some of the current legislation (mind you this was recorded before the revisions made in early August to SB 558). Go to this link to see recent parity-related posts. This leads into a brief discussion of... * MIND-BODY DUALISM. Why are there different rules for brain stuff than for body stuff? Isn't the brain part of the body? Will we still be having this debate in yet another 2400 years? * PINK FLOYD'S SYD BARRETT. Brief mention of my post last month, [Shine On, You Crazy Diamond], which, in turn, points to the "Images in Psychiatry" section of the July, 2007, issue of AJP, a tribute written by Paolo Fusar-Poli. "Nobody knows where you are, How near or how far." * THREE ARTICLES ON SUICIDE in the July 2007 AJP. The first, by Simon & Savarino, is a well-done study looking at the relationship between the initiation of depression treatment (medication or psychotherapy) and suicide attempts by looking at outpatient insurance claims of a half-million members. They found that suicide attempt rates were highest in the month before treatment initiation, and that the patterns were similar for medications and psychotherapy. See below image. Most of the people (some 90% or so) were being treated by their primary care physicians. Those with the highest risk appeared to have been referred on to therapists or psychiatrists. Regardless (and not surprisingly), the patterns were the same. As stated by David Brent in his editorial, "it is much more likely that suicidal behavior leads to treatment than that treatment leads to suicidal behavior." * 2ND SUICIDE ARTICLE by Posner et al about Classifying Suicidal Events. The Columbia Classification Algorithm of Suicide Assessment (C-CASA) is explained, in an attempt to standardize the disparate definitions currently in use across treatment trials. Click here to see examples of difficulties in defining injurious behaviors as adverse events. Click here to see the Table of C-CASA definitions and training examples. * 3RD SUICIDE ARTICLE by Gibbons et al about the Relationship Between Antidepressant Initiation and Suicide Attempts in a Large Veteran Population. This group found that SSRI antidepressants had a protective effect. "Suicide attempt rates were lower among patients who were treated with antidepressants than among those who were not..."The last few seconds is from Astronomy Domine, from Pink Floyd's album, Pipers at the Gate of Dawn, can be purchased at iTunes.The next podcast, or podette, will be a brief one (for us) which I will post this weekend (yes, two podcasts in as many days... we have to make up for lost time somehow) prior to our next regular podcast, which we will record on Aug 19, probably between 3-5 pm ET. If any other psychiatrist listeners can join in at that time via Skype or Talkshoe, let us know and we might include you as a guest on the show.

Send us your general questions at mythreeshrinksATgmailDOTcom.Go to http://mythreeshrinks.com for show notes with links.