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Archive for the ‘Shrink Rap’ Category

I took my car in to the shop last week to visit his Car Momma. I’ve been going to this garage for years and I know most of the mechanics. I’ve run into Car Momma at the hair salon with her head wrapped in a towel. I’ve heard about her son, his school activities and her home renovation projects. She’s heard about my vacations and seen my climbing pictures. I’ve always been on a first name basis with the people I know there.

This time, I had to leave the car and get a rental. I left a voice message with the rental desk and when the rental guy called me back at work I answered the phone with my usual, “Dr. ClinkShrink”. Now, my garage knows what I do for a living and it’s just never been an issue or really even a topic of conversation once the novelty wore off.

The difference this time was that the guy worked on my car was new to the shop. When I arrived at my scheduled time the next morning, he was standing in front of the shop, clipboard in hand, waiting for me. “Dr. ClinkShrink?” he asked and he shook my hand. He had all the paperwork waiting to go, my rental was lined up and waiting, and every reference to me was preceded by “Dr.”. I gotta tell ya, it felt weird. Eventually he asked me if I was a medical doctor, explaining that he asked because “there are a lot of people who go by ‘doctor’ who aren’t actually MD’s.”

My first thought was: “blog material”.

I never go by my title or my initials when I’m off duty. When I first graduated from medical school a got several letters (hand-written, pre-email) from my mother addressed to “Dr. ClinkShrink” or “ClinkShrink, MD”, but that was about it. I think (and still do) that people who flash their initials around are a bit obnoxious. This was just the first occasion that I really was struck by what initials can do. (And no, I don’t plan to make a habit of flashing the ‘MD’. It just felt too weird.)

And for the record, I did make a point of telling the rental guy that PhD’s earned their degrees too.

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I got an email from one of our readers asking for the Shrink Rappers’ opinion of an article in the New York Times by Daphne Merkin entitled “My Life in Therapy“. My first thought was: “I am sooo not the person to be blogging about this.” My clinical practice consists entirely of medication management, occasionally with additional crisis intervention and brief supportive therapy. I know that Dinah will have more to say about this story when she gets back and will probably say it better than I can. Nevertheless, I’ll give it a shot.

In keeping with the Dinah tradition, I’ll summarize the story and post a couple excerpts, then give my thoughts on it and ask for comments.

Merkin writes about her forty-plus years of experience as a psychoanalytic patient in New York City. Her first therapeutic contact took place when she was ten years old; she writes about her initial ambivalence and resentment of her therapists, what therapy has taught her over the years and also what therapy has cost her in both financial and personal terms. In spite of her professional and successful outward appearance, she suffered from repeated episodes of depression. Therapy helped keep her alive, but also occasionally provoked the symptoms she was struggling to contain:

“In therapy that was more psychoanalytically oriented…I tended to get trapped in long-ago traumas, identifying with myself as a terrified little girl at the mercy of cruel adult forces. This imaginative position would eventually destabilize me, kicking off feelings of rage and despair that would in turn spiral down into a debilitating depression, in which I couldn’t seem to retrieve the pieces of my contemporary life.”

Although she knew that therapy would not provide her with a “cure” per se, she travelled from one analyst to the next in the hope of converting her “hysterical misery” into “common unhappiness”. Finally, while looking for her last doctor, she came to a conclusion:

“Now, however, in my 50s, I only felt persuaded that the last thing I wanted was to put myself into Dr. F.’s hands. I realized that I had been carrying a “Wizard of Oz”-like fantasy with me all these years, hoping to find someone who would not turn out to be just another little man behind a velvet curtain. It was not that I found all my shrinks to be impostors, exactly, but it dawned on me that I no longer had the requi site belief in the process — perhaps had never had it in sufficient quantity.”

For the first time, she decides to try living a life without therapy: “All those years, I thought, all that money, all that unrequited love. Where had the experience taken me and was it worth the long, expensive ride? I couldn’t help wondering whether it kept me too cocooned in the past to the detriment of the present, too fixated on an unhappy childhood to make use of the opportunities of adulthood.”

There are obviously limitations to what Merkin can write about: the only type of therapy she experienced was psychoanalysis, and it was unclear to me whether or not her clinical depression was ever adequately addressed pharmacologically in spite of the fact that all of her analysts were psychiatrists. Setting aside these issues, I was disappointed in the story. Her chronological list of therapist descriptions eventually took on a vacuous, droning tone of endless disappointments. She admitted that in spite of years of experience with treatment she lacked the ability to recognize a good therapist; she judged each new potential doctor based upon their wardrobe, or the office decor. The article appeared to be mainly a depiction of the New York analysand zeitgeist rather than a progressive story of one individual patient.

Frankly, I’ve heard better descriptions of the therapy experience, descriptions that were deeply personal and more heartfelt, from our readers. Merkin’s article lacked poignancy, intensity and warmth and for me it had the feel of an intellectual exercise rather than a personal revelation.

She made one point successfully: that although the unexamined life may not be worth living, sometimes the examination of life takes the place of living.

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Dinah is away so Roy and I are left in charge of the blog, heaven help us all. Real life has taken over my blogging time so I’ve really gotten out of the habit. Also, I’ve got a 383 page proof copy of the book to review and edit by the time Dinah gets back. I may have to choose between the two tasks. Here goes.

I was listening to my Nightline podcast this morning and I heard an interview with Naomi Campbell, the celebrity model called to testify in Liberian dictator Charles Taylor’s war crimes trial. There were a number of curious aspects to the story: Campbell’s admission that prior to traveling to the country she had ‘never heard of Liberia’, and the fact that she receives gifts so often that she thought nothing about having a bag of raw diamonds delivered to her in the middle of the night, or the fact that she’s so rich she immediately gave the diamonds away to an acquaintance. I was also struck by her statement that she was annoyed by the inconvenience of being involved in the prosecution of someone accused of hundreds of murders. I’d say ‘inconvenience’ was a small price to pay for justice.

Separate from the celebrity spectacle aspect of the story, there is a back story here which I find more concerning. Campbell mentioned that she was reluctant to testify out of concern for the safety of herself and her family.

This was the issue that brought this story directly home for me and the patients I work with in Baltimore. Witness intimidation is probably the single biggest factor in the failure to gain convictions for serious crime in this city. It happens so often that prosecutors routinely take witnesses before a grand jury to testify prior to trial, to preserve their testimony before they can be threatened into changing it or they ‘disappear’ before the court date. This is not to suggest that Baltimore citizens care less about justice, or are less conscientious citizens. They have reason to be afraid. One infamous drug gang in Baltimore created the notorious Stop Snitchin’ DVD to warn people against cooperating with police; witness intimidation entered the mainstream media.

Witnesses have had their houses firebombed. They’ve been threatened and family members have been killed. Criminal defendants have even orchestrated witness killings from behind bars, causing Maryland to be a leading proponent of cell phone jamming technology in correctional facilities. Maryland has also taken legal steps to hold the perpetrators responsible, making witness intimidation a felony offense punishable by up to 20 years in prison.

I can’t say that I have an answer to this problem. I do know that hearing Campbell express her fear instantly changed my mental image of her. Instead of the fabulously wealthy, inconvenienced supermodel she became someone I felt I knew. She could have been anyone in Baltimore.

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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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A psychiatrist I know is going through a phase-of-life change. It’s one you only get to once. He’s made the comment that in looking back, he made some mistakes and said some things he shouldn’t have to patients who were going through this same phase-of-life change, long before he did. The event of it has made him more empathic to what his patients were feeling, something he didn’t comprehend until he was in the same shoes.

I know the feeling. People look to their psychiatrists for wisdom, and you know, we don’t always have it. Patients will ask for suggestions about marriage or child-rearing from psychiatrists who may be single, childless, or on their eighth divorce. It doesn’t mean we don’t have the answers– sometimes these things are better dealt with from a safe distance– but sometimes it might. I look back at some of the things I said to the parents of teenagers, back when mine were oh-so-cute-and-loving toddlers…and I wince…oh, my, I was so clueless back in the day. Can I recall my patients? I’m sorry, I said some stupid things back then. I shrug a lot more than I used to. I don’t know if it’s helpful, but I do know it’s more honest.

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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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Katina writes to us from onlinecolleges to let us know about a post on which jobs are the top ten most depressing:

Check it out here: 10 Professions with the highest levels of depression.

What I found to be interesting is that the assumption is that the jobs cause the depression.
For example:

1. Social Workers: If you had to deal with abused children, unkind foster parents and less than stellar family dynamics all day, you might be depressed too. Those working in this field are three times more likely to be depressed than the general population, and many are so focused on helping others they don’t get the help that they need themselves.

There’s nothing in the post that addresses the chicken-or-egg? question. Maybe people with depression are drawn to certain fields. Artists are listed, with the statement that those who chose to work in the field “found it depressing.” And everyone kind of gets it: doctors, nurses, social workers, lawyers, artists, janitors, food service people, finance, nursing home and childcare workers. What’s left? What’s the depression rate among bloggers?

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In case you missed Morning Edition today, it was about how grief fits into the diagnostic criteria for major depression, and the debate that went into this for DSM-V.

Want to listen? Click HERE.

Want to read? Click HERE.

Excerpts:

- Holly Prigerson, a researcher at Harvard University who studies bereavement.

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I’d rather make the mistake of calling someone depressed who may not be depressed than missing the diagnosis of depression, not treating it, and having that person kill themselves.

- Dr. Sid Zisook

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- Dr. Allen Frances

And finally: a shout out to Peter who told me about this program this morning.

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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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From the front page of today’s Baltimore Sun: Researchers Explore Link Between Schizophrenia, Cat Parasite.

Frank D. Roylance writes:
Johns Hopkins University scientists trying to determine why people develop serious mental illness are focusing on an unlikely factor: a common parasite spread by cats. The researchers say the microbes, called Toxoplasma gondii, invade the human brain and appear to upset its chemistry — creating, in some people, the psychotic behaviors recognized as schizophrenia. If tackling the parasite can help solve the mystery of schizophrenia, “it’s a pretty good opportunity … to relieve a pretty large burden of disease,” said Dr. Robert H. Yolken, director of developmental neurobiology at the Johns Hopkins Children’s Center.

Roylance continues:
A University of Maryland study last year found that people with mood disorders who attempt suicide had higher levels of T. gondii antibodies than those who don’t try to take their own lives. Still, the links between schizophrenia and toxoplasmosis are not simple. For example, most people infected with T. gondii never become schizophrenic. And not all schizophrenics have been exposed to toxoplasma. Yolken believes additional factors, such as an unlucky combination of genes, are probably needed to produce schizophrenia among Toxoplasma-infected people. The parasite’s DNA may also be important, since some strains are known to cause more disease.

Meow?

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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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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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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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