Mental Health Blogs

Archive for July, 2010

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Times are tight and we’re all looking to save money, be it our own or someone else’s. Many will say that when it comes to the skyrocketing costs of health care, doctors are responsible for part of the problem. We order too many tests, either to cover ourselves in the event of a malpractice suit, or because patients pressure us, or because we genuinely believe that the tests are necessary for patient care, but in many circumstances, a cheaper option is available. We order medications that are expensive when cheaper medications are available. And psychiatrists offer care– like psychotherapy– that could be done by clinicians who are cheaper to educate and willing to work for less money.

Here are some voices on decreasing cost: From KevinMD‘s post on when patients (in this case the patient is a doctor), pay cash. More on the same story directly from Jay Parkinson, here is Today I Was a Patient. The most absolutely cool thing I learned from Dr. Parkinson this morning is about a website I had never heard of before called ZocDoc which lets people schedule on-line appointments with new physicians (including shrinks!)–like OpenTable for Docs…I asked for more info about this, but such a website fits Roy’s vision of dying and going straight to heaven. And MovieDoc has strong opinions on allocating resources: we shrinks should not be letting patients ramble on about their romantic lives, why one psychiatrist can treat 1,000 patients if they stop that psychotherapy nonsense! ClinkShrink, too, has had a lot to say about allocation of services, but I’ll stop now before the blog explodes.

I buy it, too. Docs should feel an obligation to care about cost-containment. In recent times, this translates very simply into the fact that I feel guilty no matter what I do. I sit with a patient and I consider trying a cheaper option for medications before I try a more expensive one. But then I think: isn’t my obligation to do my very best by this patient? Why shouldn’t my patients get the latest-greatest available medication when other patients do? And what’s the cut-off for how much it’s worth for….relief from voices, a better mood, a good night’s sleep? How do we even begin to put dollar signs on such things?

I’ll give you a scenario. A patient comes to me already on an anti-psychotic medication. He says it helps, but it’s unclear why it was ever started. At some point, he stops taking it, and it becomes much more clear why he ever needed it: he becomes flagrantly psychotic and completely unable to function. I restart the medication, using the one he was on, which happens to be fairly cheap as the second generation anti-psychotics go. So all good: the med works, I know he tolerates it, and it’s the cheapest of the choices, by a lot. Oh, until he gains 20 pounds. Now what? There’s Abilify which is, oh, many times more expensive, but is less associated with weight gain…should I try that? I hesitate because of the cost, and then I think perhaps I should try one of the older medicines, of the Haldol generation– much, much cheaper, but many patients hate it. As a field, we seem to agree that these first-generation anti-psychotics are not the way to start; the atypicals are the usual first-line treatment. Maybe this patient won’t have side effects, maybe he’ll be fine, I could “try.” But isn’t that making my patient into a guinea pig? If it were me, would I want to try a medication with many known side effects, when other medications are available? Nope. So I go back and forth between what is best for my patient and what makes sense for society. I share some of my thoughts with the patient, whose private health insurance pays for them, and he clearly wants what’s best for him, not what saves society money.

I suppose the question presumes that I know what’s best for him. And clearly, I don’t. One of my big concerns is that he had this awful recurrence of a terrible illness, and each time, it takes weeks to get better,time lost from his life. There is no guarantee that Abilify, with a more favorable side effect profile, will be equally efficacious, or that Haldol, cheaper if you will, will also work. There is the risk of relapse with any medication change and this is why some patients tolerate medications that cause weight gain or diabetes.

And then there is the “at what cost?” for that particular symptom. A patient wants a medication for sleep– trazodone and benedryl don’t work, ClinkShrink flips when anyone prescribes Seroquel for sleep ($3/pill for 25 mg per drugstore.com), benzodiezepines are contraindicated, and then there’s Rozerem at $5/pill. Is a good night’s sleep worth $5 night? Of whose money? And what if the patient is on generic Ambien ($1/pill or less) but wants to take Ambien CR ($4/pill) because it helps him sleep longer? And how do you feel about Provigil, which comes in at $20 a pill for the 200mg dose? Stepwise therapy, you say— where a patient must try cheaper medications before he is allowed access to the more expensive ones? And who determines efficacy? And how do we deal with the hassles of pre-authorization? Maybe we should decide that certain medicines are so expensive that they shouldn’t be offered to anyone?

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At dusk the drone of the cicadas is deafening. For a species that theoretically only spawns every three to five years, this annual event puzzles Chicagoans. We’re confused because we hide from the elements most of the year so any summertime visual/auditory arousal throws us off.

My 8-year old grandson takes the cicada fertility boon as an opportunity to collect molted shells, the exoskeletons. He’s delighted with this process. To add to the wonderment of it all, his aunt bought him a plastic bug farm for live insects. I told her that one day, when she has grandchildren, I’ll try to return the favor.

But even an 8-year old can’t take the sight of maggots eating through the head of a dead bird. Master Scientist comes running to inform me, after my Saturday nap:

“Bubbie, you’re not going to believe this! On the deck, in a flower pot, is a dead bird! A very large, dead, black bird! And his head is only a skeleton! The worms are eating him. You have to see this!”

I’m sick at the thought, pass on the demonstration, and he totally understands. The culprit is West Nile Virus, or bird flu, some such plague. Black crows are dropping from the sky. You see them in the parks, quite dead, if you look carefully. This is an opportunity for my daughter, a good Jewish mother, to teach her son, “Now you have to be SURE to wash your hands when you touch bugs. You could catch the sickness, too.”

This is probably where it begins, I’m thinking, the female aversion to bugs, for it does seem to be associated with women, the EEEK, thing. Generations of prejudice against things that crawl, for no one likes anything crawling on the skin, and the fear of disease. Perhaps there is also a fear of the unknown, a fear of invasion. They are small. They’re fast. They hide. Who can keep up with them?

But honest. They’re so small, bugs. We can kill them fairly easily. Seven in one blow, if necessary. And RAID is amazing, has subdued many a crawling or flying six-legged monster.

A person can’t let them get the psychological upper hand. You just can’t. Even in quantity, they’re still just bugs. I can say this because aside from a few spiders and a few ants, resident centipedes and water bugs, my house is bug free. If there were other, strange, territorial, hard-to-kill bugs, I’d probably move.

We’re supposed to be tolerant, I guess, and loving. But last week we were playing a little tennis near a city garden and a bee stung my hand as I reached for a lost ball. It was a little bee, an aggressive bugger, and I got angry because I had been trying to teach the kids what I learned from the book, The Secret Life of Bees (fabulous, Sue Monk Kidd, that if you love them, bees, they won’t hurt you. Send them love.

Rubbish. Do not believe this.

Once I had a friend who told me a bug story. Her mother ridiculed her for being afraid of bugs, and she didn’t even have a fear of bugs, not in the plural. It was one particular bug that threw her off her game, a big indestructible thing.

None of us like the indestructible ones.

I have a fond memory of waking up to the sound of a mosquito buzzing in my ear, me trying to rouse my parents from their sleep. My mother groggily inspires me, “You can do this, I know you can. Turn on the light, track him down, and kill him.” She didn’t like mice, particularly, but there wasn’t a bug she couldn’t dispose of with alacrity. Once I mastered mosquito detection, it was a short step to swatting and murdering the bloody things.

So why the bug phobia, you asked, didn’t you? I think that the EEEK! thing is a combination of what we’ve already said, they’re small, they could go anywhere, but we should add the functionality of the behavior, see it, sometimes, as a coy female reaction that begs male attention. Bring out the club, caveman. We have roaches.

This vulnerability is modeled by a woman’s mother, a woman who assigned the job, killing house bugs, to a man. Not all that different than Do the lawn, dear, it’s grown to my knees. It is endearing when they come to the rescue, and gives the fellow something easy to do, something less taxing than the lawn. Some swat with a bare hand.

My daughter didn’t see a bug-killing role division, for if you remember, bugs didn’t blow my own mother away. So theoretically, knowing how transgenerational these things can be, my daughter shouldn’t have shrieked this morning when she opened her laptop to find an ant. She shrieked once, then she shrieked again when she saw another. I brought out the RAID, but she blamed herself for letting the kids eat terrible sticky things while playing Club Penguin (the Facebook entry drug).

The shriek, we concurred, was associated with the thought of insects devouring the inside of her Mac. A fairly good reason to fear them.

Now, if I hear a drone from inside that thing at dusk? Something’s going to have to give.

therapydoc

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Sarebear has been commenting on our posts for years now, since the very beginning of Shrink Rap. She sent us a link to one of her blog posts on Pie-Bolar Served w/ 3 Flavors of Anksia Tea and the post was a detailed discussion about her session that day with her psychiatrist. Lots of details and lots of sadness and angst, but a wonderful glimpse in to what happens in a session with a psychiatrist. I especially loved that Sarebear started her account in the waiting room where she sat with her family…the psychiatrist was running late and two drug reps were sitting there talking! What does a patient think about when such things intrude on their care? With permission, here’s Sarebear’s thoughts on Drug Reps in the Waiting Room:

My psychiatrist was twenty minutes late today, which means that she got in to the office at 9:20, which was when she was supposed to see ME, but her FIRST appointment, her 9:00, was still waiting to be seen, so I had to wait longer. UGH!! She said, “I’m sorry I’m so late!!”, and the other patient said, “Don’t worry about it”, but I said absolutely nothing . . . . . lol. Can you tell I was a little peeved? In early morning traffic, it takes about 35 minutes to get there, so we had gotten up early, and had gotten there 10 minutes early, even, not wanting to shave it right to the minute. I suppose everyone has an off day, though. It’s still annoying for me, as the patient! Guess I wasn’t very “patient”, heh. While I waited, just after the first patient went in, a pair of drug reps, one in training, came in, and dropped off some samples in her back room, then sat down to wait. I vowed that I’d get seen before them, because patients are more important. They talked alot of business, and about where each of them had worked, and some of the details of the software they were using on the laptop, that they wish they’d had at the previous place, and stuff. It was interesting to listen to them talk. Drug reps are a sadly necessary “evil” of the medical practice, because they provide drug samples for the doctors, without which you wouldn’t be able to start some of the initial doses of certain medications, and sometimes the samples are used to help some patients afford the medications, although they do NOT replace the pharmacy, not at ALL. The drug reps also provide coupons and promotions for the patients to redeem for free two week or one month supplies of the medication, with prescription, at the pharmacy, whenever their companies are offering such coupons and promotions, so again, these things are good for the patient’s pocketbook, their bottom line, for being able to afford the medications, when the insurance situation isn’t ideal. Obviously some of these don’t last very long, while other programs will, say, take half off the cost of the medication for a year, but whatever can help the patient, is a GOOD thing. It’s just, the whole salesman aspect of the thing, seems a little . . . smarmy. It also feels a bit intrusive, to have salesmen in the medical setting like that, but as I say, it is a necessary “evil”, even if one wonders about the influence that they may have over a doctor’s prescribing practices. The most ethical doctors will not be influenced, but no one is perfect. Anyway, sitting there for awhile, listening to them, I didn’t think they worked for Pfizer, the makers of Geodon, the medication I had been reduced in dose after my recent bad experience on, and was here today to be likely removed off of and put on possibly something else, but if they did, I wanted to tell them I thought it sucked. So, I asked them eventually, “Do you work for Pfizer?” They said, “No”, so I continued anyway, since they’d still have an interest, and they did, and I said, “Well, Geodon sucks”. They said, “We think so too, we sell a competing product.” I said “Oh, okay. I hate it, because I had unexpected side effects.” They then expressed their regrets to me that I’d had a hard time, and again said that they didn’t like the med. I thought the whole interaction was a little bit funny, hee. Normally I wouldn’t, as a patient, have any kind of interaction with drug reps at all, but since my psychiatrist was late, and since they’d been chatting for awhile so freely in front of my husband, daughter and I in the waiting room (after all, this is the type of location that is basically their workspace for the whole day; that, and their car, so one can’t expect them to just sit there silently), so their chatting had encouraged me to eventually strike up a conversation, since there was nothing else to do while I waited for the doctor. When she eventually came out, as she walked past them to the front desk, she asked them if she needed to sign something, (I assume as in, to sign for the samples they’d dropped off in her back room) and they stood up and handed her a clipboard and started talking with her, the one in training did. I wondered if he’d bring up with her anything about the competing product for Geodon, since he knew she’d be bringing me off of that one, and potentially on something else, but it seems they had enough discretion NOT to go there, which amazed me slightly, for salesmen. They just brought up the coupons and promotions that are so helpful for patients, and got the signed clipboard back, and in the middle of signing it, she called me in to the office, which helped let the drug reps know that she’d not be spending a lot of time with them, and made me feel like I was her priority. I didn’t feel badly that she’d signed for the samples, because otherwise these men would just be sitting around for another 25 minutes doing nothing, when just 2 minutes of her time took care of the whole matter.

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I’ll have some news on my work on this site below, but let me first weigh in on something far more important.

Last evening, I learned through MindFreedom that Robert Whitaker, the Polk Award-winning journalist and author of the recent “Anatomy of an Epidemic,” had had an invitation to be keynote speaker at the annual “Alternatives” conference withdrawn. The conference is funded by HHS’ Substance Abuse and Mental Health Services Administration (SAMHSA) and apparently someone at the agency freaked when they learned that Whitaker, an authority on mental health issues and a tough critic of the bio-psychiatry mainstream, was set to speak. He’s been quite critical of federal agencies (so have I). Whitaker tells MindFreedom:

“MFI: What is it that you write about in Anatomy of an Epidemic that is so threatening?”

“WHITAKER: The story told to the public by the NIMH and by academic
psychiatry is that psychiatric medications have greatly improved the
lives of those diagnosed with psychiatric illnesses. Yet, even as our
society has embraced the use of psychiatric medications during the
past two decades, the number of people receiving government disability
due to mental illness has more than tripled, from 1.25 million people
to more than 4 million people.

“So you can see, in that data, that something may be wrong with that
story of progress. And then, if you look at how psychiatric
medications affect the long-term course of psychiatric disorders, you
find — in the scientific literature — consistent evidence that they
increase the likelihood that a person will become chronically ill. I
know this is startling, particularly since we do know that some people
do well on the medications long term, but that evidence, in terms of
how the medications affect long-term outcomes in the aggregate, shows
up time and again in the scientific literature.”

Certainly, there’s a fair amount of overlap between what Whitaker argues in his new book and what I’ve argued on this site for years. But it doesn’t matter if I agree with him or respect him as a colleague (and that he was very respectful of someone whose case I’ve written about for years), he was invited to speak and should be allowed to do so. SAMHSA should re-invite him before it winds up with yolk all over its collective face. The irony that the conference is called “Alternatives” should not be lost on any of us, although you’ve got to wonder exactly whose alternatives are to be touted.

If you have any thoughts you’d like to share with SAMHSA’s director Pam
Hyde, then fire them off to her at Pam.Hyde@SAMHSA.hhs.gov.

For myself, I had hoped to be back at it on here this week. But I am simply torn up too much from a tough six-month initiative campaign to write with much clarity. I have severe tendinitis in my left elbow and much pain in both of my shoulders. All in the cause of what’s now a two-year fight to legalize marijuana in Washington State. In the process, I established a Facebook page with 9,200 fans (a larger base than several well-known, longstanding drug reform groups) and a very active website for the campaign (I did many other things as well; some well, some not so well). Both of which bode well for Sensible Washington as we prepare to launch a new legalization initiative in January 2011.

My hope is that my body will be sufficiently healed by next week to return to regular postings.

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Okay, so I’ve been complaining about the hassles with Medicare since I changed my address. So this morning, Monday at 9:23 AM I decided to call the Highmark Medicare Enrollment Helpline. I went through the assorted menus — with several stops at : Please visit the website. So finally I get to the juncture where I can press O to speak with a live person. Oh, but the message I get is: “We are currently experiencing high call volumes and can not take your call.” They suggest I call back later, and specifically suggest that the best time to call is 8AM-9AM on Mondays. Next week, perhaps? Oy.

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I’m trying to figure out the details of an organizational Facebook Page. Somehow, I made two from the same account, and so you can be our Friend on Facebook, or you can be our Fan on Facebook. There’s a duck. There’s some sideline stuff. There’s our feet. I’m hoping I can get Roy to feed his tweets to the Facebook page so that our posts will show up there. I haven’t got the kinks out, but please do Friend us and Fan us, especially in this heat! If you look for us on Facebook, we’re Shrink Rap, the ones with the feets.

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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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I’m stealing a post from Jay at Two Women Blogging—-which is interesting because it’s written by three women blogging and you’d think that three bright women could count (maybe even up to five), but okay…. Here is their stolen post and I’ll discuss it below. I think they’ll be okay with my stealing, and here’s a shout out to Tigermom.

Was Harry Right?
~by Jay

Bluemilk got me started thinking about this. I first heard Harry’s thesis advanced by the resident I worked with on my med school psych rotation. She assured me that while I might think I had platonic friendships with men, the men didn’t see it that way. I was pretty sure they did see it that way. I wasn’t naive – I was engaged to be married and had done my share of dating and flirting; I knew what it felt like when a man was interested in me sexually and I knew the difference. I still know the difference, and I still have men friends. For most of my life, my closest friends have been men.

I had a best girlfriend growing up, but we weren’t together very much – she lived in a different neighborhood and had a lot of afterschool activities and we weren’t usually in the same class at school. We didn’t trade sleepovers and call each other to check our outfits and have long closed-door talks like Eve does with her friends. My day-to-day best friend, the person I hung out after school with and rode bikes with and watched TV with and waded in the creek with, was the boy across the street. We were inseparable until he moved away when we were ten.

During that same psych rotation, we had a lecture on child development in which I learned that “all children” had a same-sex best friend during latency. I asked the lecturer afterwards what would happen if a child had an opposite-sex best friend during that period, and she said “gender development would become abnormal”. Perhaps that explains it.

I started to seek out and cultivate female friendships when I was in med school, but I find I still gravitate toward friendships with men. I am blessed, now, with wonderful women friends, and I’m deeply grateful for them, but I still think my psych resident – and Harry – were wrong.
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I picked this post to blog about because 1) I liked having the When Harry Met Sally clip in it and 2) because these kinds of black-and-white statements about How Life Works come up all the time in therapy. In the case above, the teacher tells the student that during latency one must have a same sex best friend. Must. If not, the person grows up to be “abnormal” in their gender development. Show me the science. Oh, first define for me “normal” in terms of gender development? And who out there has “normal” gender development? What’s the goal? Martha Stewart? Barbie? Elana Kagan? J Lo?

What comes up more often in therapy is the question of can you be friends with an ex-girl/boy friend? An ex-husband or wife? I tend to think that it’s usually hard, but there are people who do it, so counseling: “you can’t be friends with an ex” or “you can’t be friends with a member of the opposite sex” or pretty much any absolute, seems, well, not evidence-based. My personal favorite piece of advice– to give– along the ‘absolute,’ non-evidence based line is to tell people to stay away from the person they are so painfully breaking up with for a good long time, at least until all parties are no longer in love and have moved on with their lives. Now all I need is a movie scene.

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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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I know it’s been four months since I last posted–and I’d never planned on being away so long–but I am on my way to coming back to this site. It’ll likely be next week before I am back up to speed as I am trying to work six months of 90-hour weeks (no, I’m not exaggerating) out of my body. Suffice to say that running an all-volunteer initiative campaign in signature gathering phase is very tough work. The short story is the I-1068 campaign faced just about every obstacle you could imagine and some I never would’ve guessed at until they happened and we came up short on signatures. The main impediment was the weather: It was a very wet May and June (June was at 200 percent of normal rainfall) this year and that makes it extremely difficult to turn out volunteers to collect signatures. The initiatives that will qualify for this November’s ballot in Washington State all relied upon paid signature gatherers. Some initiative backers will spend close to $1 million just on signature gathering. I-1068 spent around $40,000.

Sensible Washington–the group I co-founded earlier this year–is already hatching plans to take another run next year at signature gathering for what I call “Son of I-1068.” So the next six months or so ought to be interesting as we ramp up for that. And pray for better weather. And more money.

I’ve appreciated the many kind sentiments that have come my way the last few months, especially this yesterday from PsychCentral’s John Grohol.

It’s interesting to be coming back just as the Avandia saga comes to a head and just as GlaxoSmithKline takes a $2.3 billion charge to settle various legal cases connected to Avandia and Paxil. Same as it ever was.

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We’ve talked about conflict and intimacy avoidance in other posts, how we learn from the examples set by our parents. It isn’t rocket science, but there are subtleties.

Those of us raised in affectionate families sometimes find physical intimacy the easiest thing in the world; it’s difficult to conceive of life without it. Feed us with love and we love back, cringe at anger. Some of us develop an allergy to anger to the degree that we’ll walk out of films, change the channel on the television when the volume feels too much.

Those who suffered violence in the home, as opposed to peace-love as children, can be conflict-avoidant, too. Others identify with the aggressor and are consciously aggressive. There are many variations here, including one in which two people are drawn to one another, feel they’re soul mates because they both grew up in violent homes of one type or another.

But expectations are everything in a relationship, and expecting a partner to be a peace-nik when you want him to be a peace-nik, just because he should, in your opinion, be conflict-aversive, having grown up with so much conflict, doesn’t make it so. If you think about it, logically it makes sense that one of the two should be good with conflict, and the other, not-so-good. Laws of chance.

And when that happens, things get pretty wild. Let’s pretend the person comfortable with conflict is a guy, and the person who is conflict-avoidant is a woman. (Substitute genders at will).

The assumption on her end is that he gets it, this soul mate of hers, that she’s had enough insults or sarcasm to last a lifetime. She’s thinking that he, too, doesn’t want to raise his voice or hear her yell, that he won’t want to behave like his parents behaved. He understands.

Yet he’s hardened off, is immune to verbal and physical violence. The continuum of violence is what is meaningful to him. A jab, a joke, a minor insult shouldn’t hurt. It’s a left-handed insult; or sarcasm, no big deal. A good fight, even, no big thing, nothing to fear; it’s something to win.

Whereas she truly could be overly sensitive. Negative communication might hurt her to the degree that she feels re-traumatized. She’s already too bruised, can’t handle any more bruises, emotional or not.

Sticks and stones will break my bones but words will never hurt me. His refrain. Doesn’t she get that?

For him it has become something of habit, rising to the offensive under pressure, and it is hard for him to change, even if she has called him on his words, told him how much they hurt.

She’s disappointed in him, is the truth, which depresses him. He senses it. She’s disappointed that he hasn’t changed, for she has said something to that effect on numerous occasions. But she doesn’t yell about it, doesn’t punctuate in the way that he’s used to people yelling when they want to make a point. So he doesn’t hear, doesn’t respond, and out of nowhere, he spontaneously cuts her with words, especially if he’s feeling attacked.

She’ll walk away, get some fresh air, won’t even say,

You know, Words hit as hard as a fist. Watch what you say.

That’s the tagline for the National Committee for Prevention of Child Abuse, highlights a poster that a patient once stole for me. She took it off a bus. I’ve had it for thirty years.

This is a simple family therapy. We revisit both childhoods, talk about feelings, explore the intimacy avoidance characteristic of the behavior of both partners.

What’s amazing to me is how long some couples endure this pattern without insisting it change. You would think the conflict avoider would explode, at some point, for exploding is necessary, to make the point. It is most typical that a child will bring a couple like this to therapy, will think of some way, act out, carry a symptom. It can take a good while for anger to become the motif of that treatment. The anger management is eventually requested, interestingly, by both partners, and begins with old fashioned insight, psycho-dynamic psychotherapy, reaching into childhood.

Only after that, will the cognitive-behavioral strategies really work, the self-relaxation, the breathing, integrating a positive parent figure, the one we all want to be. There are a host of anger management techniques. They don’t work, not until you get to the root and yank it out, because it is primitive anxiety that drives the conflict as well as the conflict avoidance.

You can’t really apply a band-aid to the deep stuff is the truth.

therapydoc

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