Mental Health Blogs

Archive for January, 2010

I throw my backpack into the backseat, announce to FD:

I’m doing something radical. I’m just leaving my phone in the back of the car.

He goes into a rant:

You, on a bad day, checking email while driving, texting, answering calls, making calls, talking on the phone. . . you’re still a better driver than most people. I think it’s about skill, attention, coordination, . . .blah, blah, blah.

And that is so about denial, I tell him.

It is radical, and delicious, I learn, driving without the extra stress, without having to attend to one more thing. You find yourself changing channels on the radio, figuring out how to do this without ever taking your eyes off the road.

And would you believe? As I’m thinking about this, about how scary it is, knowing that the guy in back of me, the woman in the car in front, is tempted to distract, that song comes on, Your Song. Rod Stewart is singing it, not Elton John, and it’s even better, something else FD would disagree with me about.

How wonderful life is, while you’re in the world.

They all have people, probably, most of them, that they value, that they don’t want to lose, who don’t want to lose them for the sake of a lousy text.

Makes you kind of wonder, doesn’t it, what we’re doing?

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It’s snowy here in Maryland.

First, let me say that it’s never okay to lie to your shrink. Therapy is about having an honest interaction, and a psychiatrist probably can’t help someone who is hiding a secret life. This post, however, was inspired by Clink’s last piece, Rage Against the Machine where she wails on Electronic Medical Records, in a feeble and failed attempt to engage Roy in a fist fight. There she is a punchin’ and he’s just skating along oblivious as can be.

Why do EMR’s make me uneasy? When I’m in the clinic with patients and I can access their medical records, well, it makes life easier. So why don’t I like the whole idea? I talked about some of this in the comment section on Clink’s blog post.

With an EMR, it’s easier to get records, and any doctor in an institution who treats a patient has access to them (oh, the whole institution has access to them, but only those involved in the patient’s care are allowed to “peak”). What if a patient wants to withhold some of their information from certain docs? Is that lying? Is that reasonable? Should that be allowed?
If it’s about obtaining prescriptions for controlled substances, it’s just wrong. But might there be other reasons a patient would want to control the flow of information?

Let’s face it, some docs and some patients don’t click. A patient may feel the doctor didn’t really listen, saw him much too briefly and jumped to a conclusion without hearing all the information, or was uneasy with the doctor’s conclusion. The patient comes for treatment of his headaches, and after a few minutes, the doctor says it’s “Stress.” The patient wants more tests done, the doc feels it’s unnecessary, and the patient would like to get a fresh opinion. Electronic Records may hamper the ability to get a fresh opinion. The next doctor may look at the note and agree with the patient that more testing should be done, or he may see another doc’s opinion and go with that. And who knows what the first doc wrote, it may continue to prejudice future care. All sorts of human emotions get tossed in here: What if second doc hates/adores first doc, that may prejudice what side he takes. Any way you dice it, if the question is so much as raised that a patient is malingering or that an illness is factious, medical professionals may shut down.

So how does this pertain to psychiatry? Psychiatric patients are often given sub-par medical care. Their medical symptoms are more likely to be attributed to their psychiatric disorders (and sometimes this is appropriate after a reasonable and thorough work up). Perhaps a patient worries that if he tells a doc he’s in therapy, his problems will not be considered as valid. I think this is getting better.

Roy would say that the patient should be involved in the evolution of the record. Maybe Roy should say what he wants to say….

And you didn’t really think I was going to say if it’s okay to lie to your doc!

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Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

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Say you are traveling in a foreign country, trying to find your way through the bustling capital city. Not Paris or London, some place a bit edgier. Bangkok. You don’t speak the language, and you’re a little frazzled. You walk into a café for some respite, and to your surprise to see a fellow you know from back home sitting at a corner table, sipping coffee. He’s hardly a friend, but you know him to say hello. How do you feel? Well, after the initial surprise, you probably feel a warm glow as you walk up and greet him. You’re genuinely happy to see his familiar face in this strange place. He’s like an old friend.

Now, simply switch cities. You’re back at home and the same basic scenario takes place: You walk into a café, and there’s the same acquaintance, sitting at a corner table sipping coffee. How do you feel today? Well, if you’re like most people, you don’t feel much of anything. You recognize him, but no smile comes to your face. You might nod hello, but you’re really more focused on getting your morning coffee.

Same face, similar scenario. So what’s going on here? Are you a couple of hypocrites? Well, don’t feel bad. First of all, he’s probably not feeling all that warmly toward you either. And what’s more, your own mixed feelings are probably beyond your control. That warm glow of recognition may be hard-wired into your neurons, but it’s also tightly entwined with other emotions, notably fears about personal peril and a yearning for safety.

At least that’s a theory, which a team of cognitive psychologists have recently been testing in the laboratory. According to Marieke de Vries of Radboud University Nijmegen, in the Netherlands, people naturally feel good when they see something recognizable and familiar. That’s because things that are familiar are—generally speaking—less risky. This is the same impulse that makes us buy the same soap or automobile over and over again: It’s worked in the past, so it’s likely a safe bet again today. With recognizable people, that positive feeling, that sense of comfort, often feels like a warm glow.

But it may not be quite that straightforward. De Vries and her colleagues wondered: Wouldn’t the power of familiarity depend somewhat on the context? Specifically, isn’t it possible that mood might modify and shape the mind’s response to familiar and unfamiliar things? Is that what’s occurring when you feel a warm glow in Bangkok and a big yawn back home? They decided to explore this idea experimentally.

Instead of using people’s faces, the scientists used abstract patterns of dots. Basically what they did is familiarize volunteers with some patterns and not others; then they measured their responses when they saw the familiar patterns later. But they didn’t simply ask them which ones they liked and which ones they didn’t; in addition to doing that, they attached electrodes to their faces to detect subtle physiological signs of smiling. In other words, they measured the body’s visceral response to familiarity and novelty.

But before doing this, they manipulated each volunteer’s mood. They asked some to think of sad events in their lives, and others joyous events; and then they played mood-appropriate music to maintain the gloom or happiness. The idea was that mood “tunes” the mind toward safety concerns. That is, if our mood is good, we assume we must be in a safe place; if we’re feeling edgy or down, that must be because we’re threatened in some way. The researchers predicted that feeling blue (and therefore unsafe) would make familiarity an especially potent cue; feeling happy (and therefore safe) would make that cue much less significant.

And that’s precisely what they found. As reported on-line in the journal Psychological Science, the volunteers who were melancholy smiled much more at the familiar patterns than did those who were upbeat. Think about that: Familiarity wasn’t all that important to people who were already feeling secure; they already had the safety of their local coffee shop. But people who were feeling uneasy and threatened experienced familiarity as very comforting—even when the familiar stimuli were nothing more than meaningless abstract patterns of dots. No wonder the face of an “old friend” can seem so welcoming in a Bangkok café.

For more insights into the quirks of human nature, visit the “Full Frontal Psychology” blog at True/Slant. Excerpts from “We’re Only Human” also appear regularly in the magazine Scientific American Mind. Wray Herbert’s book, On Second Thought: Outsmarting Your Mind’s Hard-Wired Habits, will be published by Crown in September.

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As if there hasn’t been enough bad news around anti-depressants and pregnancy of late–formerly assumed to be safe, now linked to preterm births!–there is news of a new study showing that SSRIs can cause delayed lactation. I think I’ll just let that stand for itself without comment.

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Imagine this hypothetical scenario: You’re at a cocktail party and the host introduces you to a stranger, whose name is Jeremy. It’s a crowded party, and as you chat with Jeremy, you’re also picking up snippets of another conversation nearby. Something about a big football game on Sunday. It doesn’t concern you, so you try to tune it out. You have a short but pleasant conversation with Jeremy, then go on to mingle with other guests.

What do you remember when you run into Jeremy the next day? Well, if you’re young, you will probably recognize Jeremy’s face and associate his face with his name. That’s normal social memory. But if you’re older, you may have a very different kind of association: You may inexplicably link Jeremy with the upcoming football game. That overheard chatter about football is an irrelevant piece of information—you don’t even like football much. But your mind has been distracted by it, and it has connected that unimportant tidbit with your newly forged memory of Jeremy.

This is just a theory, which scientists call “hyper-binding.” That’s really just a jargony way of saying that the elderly remember a lot of useless information by attaching it to important new learning. But according to new research from the University of Toronto, such seemingly haphazard learning might be a blessing in disguise for the elderly. Psychological scientists Karen Campbell, Lynn Hasher and Ruthann Thomas recently ran a laboratory version of the cocktail party conversation to see if the phenomenon is indeed unique to the elderly—and to explore its possible benefits.

The experiments were fairly technical, but here’s the gist: The researchers recruited two groups of volunteers, the first about 19 years old and the second in the mid-60s. They showed all of them a string of pictures that were superimposed with irrelevant words. That’s like meeting Jeremy and hearing sports chatter at the same time. The volunteers were told to ignore the irrelevant words, and later on they were given a memory test for pictures and words in different combinations. They wanted to compare the older and younger minds at work.

The results were dramatic. As reported on-line this week in the journal Psychological Science, the older volunteers were clearly unable to ignore the distracting information even when they were instructed to. They stored away the irrelevant words by linking them tightly with their corresponding pictures in memory. What this suggests is that the elderly have weaker mental regulation and a broader “bandwidth,” taking in important and unimportant information indiscriminately. They store this new knowledge for later use and what’s more, they do this without even being aware of it.

Wouldn’t such distractibility be a terrible hindrance? Wouldn’t it just clutter up the mind with a lot of junk information? Not so, say the Toronto scientists. In fact, it may well be an advantage for the elderly. Aging often brings with it some mild cognitive declines—and indeed the elderly were slower and less accurate in some parts of these memory experiments. But awareness of how events connect in everyday life—even seemingly irrelevant events—may play a critical role in certain kinds of reasoning and judgment. In this way, distractibility may surreptitiously bolster everyday problem-solving.

The fact is, we never really know for sure what information in our world is important or useless—not when we’re first encountering it. The elderly mind may not be as fleet as it once was, but by being unfiltered, it perhaps is making connections that aren’t literal or obvious, and can be insightful. It might even be the foundation of a novel kind of intuition that comes with aging, or perhaps even what we call wisdom.

For more insights into the quirks of human nature, visit the “Full Frontal Psychology” blog at True/Slant. Excerpts from “We’re Only Human” also appear regularly in the magazine Scientific American Mind. Wray Herbert’s book, On Second Thought, will be published by Crown in September.

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I’m posting this for ClinkShrink at her request. She’s in jail at the moment and they block Blogger. This is in honor of the Apple Tablet announcement today, and she’s looking to pick a fight with Roy!

Rage Against The Machine
—by ClinkShrink.

With the pending announcement of the long-awaited Apple tablet, and on the heels of my new programming project (an iPhone app), I’m thinking about health information systems. This blog post is a blatant attempt to yank Roy’s chain, but I know he’s smart enough to see right through it. Nevertheless, if he totally agrees with me I’m going to be quite disappointed.

The fact of the matter is, I’m a geek and I love technology but I really really dislike health information systems. I’ve yet to meet one (other than stuff I’ve designed myself) that doesn’t drive me screaming into banshee land.

I know all the supposed benefits of healthcare information systems: they’re supposed to improve care by allowing communication between providers, they’re supposed to reduce healthcare costs by improving efficiency, they’re supposed to contribute to medical knowledge by collecting aggregate data about diseases for research.

I also am concerned about the downside of health information systems: potential threats to information security, harmful uses of the data that’s collected, breaches of confidentiality and loss of independent medical decision-making.

Fine. That’s not why I’ve hated them. The reason I strongly dislike most systems I’ve used is because they make it harder to figure out what my patient really has.

Psychiatry is a descriptive art. You make a diagnosis through observation and description. You treat people through language and free communication. Information systems stifle all that. Instead of being able to document that the patient “believed he was the President so he hopped on a bus to Washington, camped out on Pennsylvania Avenue for three weeks, then climbed over the fence of the White House”, I only get to check a little box that says “delusional”. Now, that really loses something.

Even when the computer programmers give me a textbox instead of a checkbox, I run out of room to document the treatment history of a really complicated patient. I could type for ten minutes about the stuff I want the next clinician to know, only to discover that my keystrokes have been brutally ignored and rejected by the $#@!J$#* healthcare interface.

I am a geek. I want my machines to obey me. Instead, I am forced to let the machine convert my prose into categories, to shave off the nuances and color and “flavor” of the people I treat, all because the system is designed by engineers rather than clinicians. I am peppered by little popup warnings about contraindications and medication interactions that only occur in one out of every 10,000 people. I have ignore these so regularly that I fear missing the one that might truly be dangerous.

Will the benefits of a national health information system outweigh the risks? Better yet, will doctors be able to use them without wanting to smash a keyboard over somebody’s head? Only time will tell.

So, that’s my take on the ‘con’ side of the national information system. I’ll leave to Roy to be the ‘pro’.

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Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

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In a fascinating piece in the Boston Globe, which echoes one of my regular themes about weight gain problems with psych meds, Harvard psychologist Paula Caplan delivers some shocking news about the forthcoming DSM-5:

“Another disturbing link could be on the way. The fifth edition of the major psychiatric diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), is expected to be released in 2013. One proposal under consideration: listing obesity as a mental illness. That would be a mistake, since obesity can be caused by metabolic and other physical problems that are often undiagnosed. And because obesity can also result from psychiatric drugs, calling it a mental illness would create a vicious cycle: Someone is troubled, put them on drugs, they become obese, therefore diagnose them as mentally ill, give them more drugs.”

Every so often I just have to say it: psychiatry has absolutely lost its mind.

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Well, this ought to be fun for AstraZeneca to explain in court. The BBC is reporting that a former UK AZ executive was pressed by AZ marketing execs to lie about weight gain issues with Seroquel in the late-1990s.

“John Blenkinsop, the company’s former UK medical manager, claimed he was pressurised by the company’s marketing arm to approve claims about the drug which he felt did not reflect the medical evidence.

“‘The clinical studies at the time of the launch of Seroquel showed patients developed significant weight gain, significant both statistically and clinically,’ he told the BBC’s File on 4.

“‘They [the marketing team] came at me with a number of potential claims all of which were trying to intimate that Seroquel was not associated with weight gain – the data pointed in the opposite direction,’ added Mr Blenkinsop who was speaking publicly for the first time since he left the company in 2000.

“He said: ‘I understood where they were coming from. I had some robust discussions and exposed them to the data but that didn’t seem to stop them because they were desperate for a differential advantage over one of the competitor products and they didn’t have one.

“‘In the end I was put under quite a significant amount of pressure by the marketeers to sign off claims with regards to the lack of weight gain and I was unwilling to sign that off. The marketeers made it clear it could be career limiting for me,” Mr Blenkinsop added.’”

Of course, this weight gain would have absolutely nothing to do with diabetes associated with the use of the drug, so there’s no need for the public to know.

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Intent.com’s question of the week is “How to Look and Feel Younger”. Here are a few suggestions:

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Today (Tue Jan 26) at 12:00 noon Eastern Time, Gregg Masters (@2healthguru) will be interviewing Dirk Stanley, Tim Sturgill, and me about Flower on BlogTalkRadio.  Flower promulgates the message that we should control our health data and have universal standards for sharing it.

Here’s the blurb about it that Gregg wrote for the hour-long live show on BlogTalkRadio:

What is flower? At this time it’s an abstraction — a placeholder for several concepts centering on what would healthcare look like if….? And, more specifically what would personal health information (PHI) look like if….? A flower was chosen as the abstraction because it is easily and universally understood, regardless of language, anywhere in the world — a flower is a flower. Where a flower is flower carries the additional abstraction that there is a common ground — characterized by property and implementation. While a fluid and dynamic idea, this informed panel will provide both history and context for its genesis and diverse unfolding narrative. Join Dirk Stanley MD, @dirkstanley, http://twitter.com/dirkStanley, Tim Sturgil MD, @symtym, http://twitter.com/symtym, and Steven Daviss MD, @HITshrink, http://twitter.com/hitshrink, as we discuss Flower’s granularity and transformational potential to make sense of a complex and moving target: informatics, health care and the patient. For additional context and insights on ‘Speak Flower’ see: http://speakflower.org/, and the threaded discussion on Howard J Luks, MD, blog: http://hjluks.posterous.com/thinking-about-flower-a-concept-is-born-hcflo

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Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

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