Shrink Rapping

Farewell to Blogger; Hello to WordPress!

2011-03-09T15:55:00.003-05:00

Hello to all.

Shrink Rapping is moving!

I appreciate all of you who have been faithful readers since January of 2009, and I would like to invite you to move right along with me.

You may now read all my previous entries from Shrink Rapping, and all the new content to come, at www.gregsmithmd.com. I describe this new forum as "One psychiatrist's thoughts about the world". Please feel free to sign up to get news about new posts sent directly to your mailbox, access the content via RSS through your favorite reader, and leave comments as you browse posts old and new.

I will of course leave Shrink Rapping up for now, but will no longer be adding new content here.

Have fun visiting the new place for one psychiatrist's thoughts at www.gregsmithmd.com. Happy reading!

Greg

Knee-Jerky

2011-03-08T06:44:00.003-05:00

Sometimes I say things without thinking.

I'm sure you do too. I'm sure at the time that I'm feeling very clever or witty or funny and that everyone is hanging on my every word because I'm so wise. You get the idea. Well, not. Just not. These things that I say sometimes, they might indeed be hilarious, but at the expense of someone else. They might make me feel like I'm very funny, but only because I've pointed out something that is not funny at all to the party that is impacted by my mirth. I might feel superior or smart or talented or large and in charge, but if the things I say (or do) bring someone else to their knees in the process, well, am I really lifting myself up, or am I tearing down the race? You know, in a cosmic sense. Dig it? Oh, yes, I am ashamed to say, I have done this. In person (ouch). On Twitter (millions of potential readers? Double ouch). Other places. I have done it, and I am not proud of it.

I have used knee-jerky. I have wadded it up and put it in my mouth and felt the bite and the flavor and the spice of it. I have chewed it and felt the juice roll down my chin and wiped it on my sleeve. I have spit a little of it out on the ground. I have felt its raw flavor and then I have swallowed it, and it does not always sit on my stomach so easy, no, not at all. Sometimes it sits there for a while, it stews, it digests slowly. Hell, sometimes I feel it creeping back up, regurgitating and burning me just a little. Not enough to permanently scar, but enough to let me know that it's there.

Moron. Mental case. Touched in the head. Crazy. Wacko. Retarded. Brain dead. Idiot. Neanderthal.

Knee-jerky.

Have you chewed on any lately?

My best advice to you (and to myself)?

Spit it out.

Switch to sugar free mints.

When Worry Met Dally

2011-03-06T10:53:00.002-05:00

It started about two weeks before Christmas as a feeling of tightness, cramping, and pain in my buttocks and hips.

I work primarily as a telepsychiatrist, which means that I can be sitting down for most of a sixteen hour shift seeing patients and typing notes into an electronic medical record. I thought, smart man that I am, that I was simply not getting up and stretching enough between consults, or that I was sitting in such as way that the chair was doing a number on my sciatic nerves, causing the pain and discomfort. I tried to sit in another chair for a week or two, I put a pillow underneath my bad self, then two or three pillows. I got up and tried to stretch at every opportunity, even taking to doing laps around the hallways to limber up a bit. I told myself that this would pass, that it was nothing, that I could handle it, and that I was being foolish to even worry about it. I soldiered on.

Then one morning I could barely get out of bed. The morning stiffness in my hips, legs, and knees was so bad that I had to barrel roll myself out from under the covers and onto the floor. It then took what seemed like an hour for me to stand upright and get myself into a hot shower, which was like manna from heaven on my body, which was already tired at six AM. Sitting down and putting on my socks was absolutely exhausting. I felt like a ninety year old man. It finally hit me. You are a fifty three year old man who just trained for and walked a half marathon on your birthday in October. Something is wrong with you, my friend. Something is really wrong. You need to see a doctor.

This realization, being a doctor and now knowing in my head and heart and hips that I needed to see a doctor myself, that I was about to become a patient, was disconcerting if not downright frightening. I have never really been sick. Oh, yes, I've had appendicitis and I've broken my leg sliding into second base (yeah, that was really stupid-another story for another day), but I've never had anything stop me in my tracks and keep me from putting on my socks and getting into and out of my car without outright yelps of pain. Something is wrong with you. NO! Yes. You need to see a doctor. NO! Yes, you idiot.

This was when Worry met Dally. Worry won.

I was so afraid that I might have something that would maim me for life or disable me so that someone would have to put my socks on for me or drive me around or that it would (gasp) KILL me, for God's sake, that I finally decided to make the call. I'm glad I did. I was diagnosed with a condition that, it turns out, my father also had, called polymyalgia rheumatica. It's serious enough, but it won't kill me. It's treatable, and my pain and discomfort are much better than they were three months ago. I know what this is, I know how to treat it, and I will be able to live with it. I know what to watch for in the future. If things get worse, I can deal with it. I now joke with my wife and kids that with my growing collection of medical ailments that I will get myself a silver Bat Masterson cane to walk with (and bop people on the head with when they annoy me), a nice blue handicapped sign to hang on my mirror when I can no longer walk from my car to my office, and a nice chocolate Lab to be my traveling companion when I go blind. (My black Lab Holly is much too old and set in her ways to help me out there, so I won't even ask her).

I can kid myself about this now that I can move again, but the moral of this tale is very serious. You know your body better than anyone else, including your doctor. If you develop symptoms that are serious, that last longer than a few days, that cause you discomfort or disability or impair your ability to function, please do not do what I, the wise and wonderful wizard of a doctor, did. Do not dally. Get checked out.

Thankfully, I did not have anything that would kill me if not diagnosed and treated right away.

You might not be so lucky.

Losing It

2011-03-05T10:40:00.002-05:00

As a psychiatrist, part of my job is to listen as you tell me about symptoms that bother you every day. If I can help you put these symptoms into a framework such as a syndrome or a disease, then we can work together on trying to figure out how to treat them. Often times in mental health, the best we can do is to dampen the symptoms and make them better or more tolerable because we haven't figured out exactly how to get rid of them completely yet. Frustrating for you and for me, but at least your life can be more enjoyable and you are not plagued by intense depression, debilitating manic episodes, or maddening hallucinations.

Now, we all would usually agree that getting rid of symptoms and curing disease are two admirable goals that are well worth pursuing. Much of medical school and residency training for doctors involves diagnosing, treating, and getting rid of pain, symptoms, suffering and disease. Lord knows, when I recently went to my doctor for diagnosis and treatment of severe pain that was measurably cramping my style every day, I had every expectation and confidence that he would listen to me, examine me, diagnose something, tell me about a cure, and fix me! He pretty much did that, and though I will not be cured from this syndrome, I feel much better and can go about my life with only moderate pain and discomfort.

What about psychiatric symptoms? Does the same hold true there? Well, of course, you would say! Who wants to suffer from sad mood and shyness and inability to go out of their home and hearing voices and social isolation and decreased appetite and all these other myriad symptoms that patients tell me about every day when I ask, "What brought you in to see me today?"? You would say, emphatically, that all patients with mental illness would want to be cured and rid of all their psychiatric symptoms and all their behavioral problems and all their social faux pas. You would say that, right?

Sometimes, you would be wrong.

I have started patients on antipsychotic drugs that got rid of the hallucinations that they had been plagued with since they were teens. All the voices-gone. The scary shadows on the wall-gone. The command hallucinations telling them to kill themselves-gone. But, the pretty, soft, soothing music that played in their heads when they lay down on the couch to try to sleep at three AM? Gone too. The positive affirmations that play in their heads that tell them that maybe things will be OK after all and to hang in there-gone along with the grandmother whose voices they conjure. The lithe, thin, physical body they'd had for years-gone with the weight gain that can come with medication treatment, just at the time that they feel like getting out and wearing a swim suit in public for the first time in their lives at the beach. The desire for intimacy, emotional and physical, with another human being-gone with the "bad" symptoms when the medications they take completely shut off a wakening sex drive that gets better when their mood improves, or that cruelly causes sexual dysfunction just when desire is returning.

So you see, sometimes losing symptoms and fixing syndromes and diseases is a tricky business indeed. While we very much want to help patients get better and function in life the very best they can in spite of their mental health problems, sometimes we take away the very things that help them care, connect, and cope.

This is why medicine, in spite of all the high tech and the wonders that we possess, is still an art.

Cookbook medicine is a fallacy.

Compassionate medicine is a worthy goal.

Get RID of It!

2011-03-04T09:01:00.002-05:00

Ok.

So you like to read, yes? You read stuff for work, stuff to get the news, stuff for fun, stuff to learn more stuff. You read things on your iPad, on line, through RSS feeds, on news readers of various types, in apps. You pick up newspapers, books, magazines. Some of these are real, in that they are held in your hands, and some are "held" virtually in your device, whether it be Nook or Kindle or iPad or other. Are you getting the same feeling I'm getting? Is the ever increasing amount of information getting to be too much for your poor addled brain? Is this pile of stuff too daunting to deal with?

I have the answer for you.

Get RID of it!

Well, not literally. You really don't want to stop learning or taking things in, but there MUST be some way to filter all this stuff so that we feel that we're learning things that matter to us. Things that make our lives better. My answer, something that I'm trying to do myself and that I challenge you to do as well?

RID = Read In Detail.

I'll spot you the weekend to figure out you want to approach this, but the gist of it is this. As all of your usual information sources pour out their bounty on you today through Sunday, pick ONE topic or interesting subject that you really want to learn more about. Something that interests you, something that you need to learn more about so you can impress your girlfriend, something you need to know to do your job better. Then, let everything else take a back seat for ONE WEEK (you pick the start day) and Read In Detail about that topic. Notice that I did not say let everything else GO, but just let the other noise fade into the background for a while. The world will not end, trust me. Google it. Go to the library. Download something from the Kindle Store. Find a review article about it. Watch a movie about it. (Well, that would technically be cheating, but I like movies so I'll let it slide if you want to do this to mix things up a little).

Read In Detail. Learn. Absorb. Get the skinny. Go beyond the buzzwords and understand the nuances. Be able to explain a new concept to your spouse, your boss, or your kid. Explain it so that the other person actually understands it.

Modern life is full of information. We are being bombarded with more information in a single day than our ancestors were exposed to in their entire lives. Don't be intimidated by it all and give up.

Get RID of it. Read In Detail. Learn, Understand. Share.

We'll all be better off if you do.

Visual Communication

2011-03-02T07:09:00.004-05:00

My online friend Bryan Vartabedian over at 33 Charts wrote a blog post on 2-18-11 about how he structures his patient interviews. Read it here. It gave me pause and got the wheels turning.

As I am interviewing you as a new patient for the first time, a lot of information is being shared (we hope!) back and forth. I ask questions, you answer, that leads to more elaboration, and on we go. The whole key to this process, of course, is to get to some kind of understandable, workable diagnosis of a problem that can then be better understood and treated, making you feel better than when you came in. That's the ultimate goal for me. I want you to leave feeling that you have learned something, gotten relief from your symptoms, or that you have a plan for tackling something that has been giving you trouble.

Bryan mentioned using a whiteboard to write things down as he explains lists of symptoms and key issues that might impact patient care. I have never thought of doing this in psychiatry, but it intrigues me. Instead of just keeping my usual notes on a clipboard to be used to type information into the electronic medical record after you leave, what if I actually got up and brainstormed with you at a whiteboard after the "formal" part of the interview was over? What if I wrote down key symptoms, possible diagnoses, and outlined potential treatment plans visually on a board so that we could both see them more clearly? It strikes me that at the end of a psychiatric diagnostic interview today, which is more like a thirty minute Board exam (pun entirely intentional) than a clinical encounter these days, that I fire an awful lot of info about disease states, medications, therapies, appointments, testing, and referrals at you than you might not be ready to hear right then. A visual aid might be helpful. There is the added bonus that I could then snap a picture of this information that we had covered and somehow get it into the EMR as well so that we can refer back to it later, reviewing and modifying what we thought about at that very first visit.

What do you think? Would a visual helper such as a whiteboard be helpful with communication in the mental health setting when you see a psychiatrist for the first time, or at follow up visits later? I'd love to hear what you think.

Thanks, Bryan, for this little nudge to my brain this morning.

If U Kan't Spel, Peasz Dont Right

2011-03-01T06:30:00.002-05:00

OK.

This post iz an ezy one fur me to right. I love to rite about my pet peavs, becase I am passhionate about them of corse. Lots of u luv to right. I know you do, becase I reed your stuff almost evry day. I realy lik most of it-I really do. You are onest with yur feilngs, you put yur thots rit out there for all of us to see, and you have some origenal idees that you wont us to think about.

You think thru the post, you chooze your werds karefuly, you spend a little time at the keebored, and wahla, a knew letter or blog post or artikle or editorrial is borned. It goes out to the internet and reeches millions of reeders. It makes an impack. It teaches peeple things that they never new befor. I applaud you for that.

However, my per peave is that many of you relie of things lik spell chekkers to catch the mastakes taht you mite make as you send out this good informashion. It is much easier to finnish writing, click on a buton, leeve the heavy lifting to the computter, and call it done. If it gets caught by the chekker, it's all good. If not, well, one or two mitakes wont hurt anybdy, rite?

The problem is, whether or not it's a tecknical document, a letter, a blog post, an editoreal, or even a note in a medical rekord, eventully somebody else is going to reed it adn try to understand it. The speeling and grammer mistakes that litter taht little jem of a document that you rote are going to take away from the genyous that I know is there, lerking in the back ground waiting to be transferred to the reeder.

Do me adn the rest of us a favur? Pleese, pleese, pleese, prufreed you're on work. Check the spelling. See if it flows, if it makes since, and if the words are spelled correcly. It will make reading your idees, which I am quiet sure are worth my time to reed, much more plesent.

Have a grate Tusday!

Doctors Without Borders

2011-02-25T06:58:00.002-05:00

Ok, so when I was in college and medical school, long years ago in the age of knights and castles and fair ladies and pathology pot cases and microscopes that had real slides with real stains, we used to hang out to study. We went to Krystal, because Krystal was open any hour of any day or night, including holidays in those days if memory serves. Krystals were cheap ("Take home a sackful", remember?), good and consistent. We went to Dunkin Donuts, because, oh my God, it's donuts, for crying out loud. Yeah, they had barley soup too, and pretty good large coffees to keep you going as you studied for that micro test that you wanted to blow out of the water, but OH MY GOD it was the donuts, right? Am I right? We bellied up to the counter or commandeered a group of tables and set up base camp, established radio connections, and went at it for hours on end. We would order another something just when the fetid breath of the night shift manager was felt hot and heavy on the back of our necks. Spend a buck, get another hour or two. Just like a budget parking meter for starving students.

Later on, many years later on, we have all turned to other places to hang out and study and talk and listen to music and do other things. We do this as teenagers, we do this as college students and medical students and residents and we even do it as middle aged guys like me who have long since forgotten where they stashed the cap and gown and have been at this game for longer than they want to admit. We go places that are not our own places to hang out. To have an experience. To just be in another space. It's all good. It's a fun thing to do, and it can even inspire creativity and help you relax and pump you up if you need that (quad espresso, oh geez, please, yes, hit me again, Mr. Barista). We have gone from spreading out our piles of papers and books and charts and lab reports and projects to lugging our huge, seven pound HPs to flipping out our cool BlackBooks (did you have one of those, yeah, did you? Sweet) to now casually reaching over, bending at the waist and taking out our 1.5 pound iPad, with ONE HAND, and casually setting up the DODOcase so that the angle is just right for the person at the next table to see how cool we are without seeing our precious data (which includes our all-important Twitter stream and Facebook homepage). We might, we just MIGHT, even venture into one of these places one day with (gasp!) just an iPhone 4 and a set of Bose earphones (the newest ones, of course, with the little plastic inserts so that everyone KNOWS they are the newest ones) and proceed to run the government of Sweden via Go to Meeting over WiFi. Awe-some.

Well, boys and girls, Borders has been one of those places of late where you could watch this ongoing, ever-changing dance. So has Starbucks and maybe even Barnes and Noble. Maybe even Dunkin Donuts still, if you're really stretched. But, alas, Borders is on its last legs. It is turning the page on its final chapter, closing out another installment in a miniseries of...well, you know. It is CLOSING. Oh, geez. All that congregational space. All that coffee and those little pastries. it's like closing down and de-sanctifying a church, for God's sake. Medical students, college students, DOCTORS without BORDERS? Where will we congregate? Where will we talk? Where will we plan and scheme and brainstorm? Where will we listen to bad music on Friday nights (well, he's a friend and he's just getting started-cut him some slack, OK?)

The sad fact of it is, my friends, is that we have met the enemy and he is us. We have gradually, slowly and surely stopped sharing projects, taking them physically off the tables and putting them into Microsoft Project or other software systems. We have left the books on the shelves opting to download them to e-readers or gulp them audibly. We have quit talking to each other, with every person you see around those shrinking tables attached to a device by two tiny little cords running into their ears, stimulating one part of their cortex but completely shutting down another. We have stopped interacting with each other in real time the way we used to at Krystal at three AM. It's sad, but it's true. Borders is but a casualty of this war on real reality. Virtual reality, virtual networks, virtual friends, virtual mentors. They have virtually taken over our social spheres.

I will miss those gritty, scary, seat-of-my-pants times. I really will.

How about you?

Melting Pot

2011-02-24T06:19:00.002-05:00

Why can't the world be more like the Y?

I go there three or four times a week now, as schedules permit, to walk on the treadmill, do a little light weight work, stretch, ride a bike, and have some coffee for the road (my favorite part of course!). It's a good place to be, a healthy place to be, a fun place to go where you know you're always welcome, the staff members smile when you come in and tell you goodbye when you leave. You feel welcome there.

There is healthy competition on the basketball courts this time of year. Gangs of would-be Michaels and Kobes tear up and down courts firing three-point shots and leaping for spinning slam dunks and then turn around and do it all again going the other direction. They battle fiercely, but in the end they all shake sweaty hands and go to the same showers and tell stories and laugh and go back home to their families. The play by rules, sometimes moderated by someone in a zebra-striped shirt, but sometimes not. Even when the whistle-blowing zebras are not there, everybody knows that there are rules to be followed. Of course there are rules to be followed. How could there be order and safety if there were no rules?

There are individuals, free spirits who do weird things with medicine balls, going up and down the spaces in between machines, dipping and crunching and crouching and flexing, up and down with that ball, up and down, then back up the aisle toward the front again. There are big strong men whose muscles bulge so much that you wonder how they can keep shirts. There are the old athletes whose heads still feel twenty but whose fifty year old bodies have betrayed them. They are still very much in the game, though they are a little wistful watching the Jordans flying on the basketball court next door.

There are the sick, the recovering, the partially lame, the post-stroke rehabbers, the post-cardiac-event guys, the amputees, the partially paralyzed young lady who transfers herself from wheelchair to weight bench as easily as the rest of us brush our teeth. There are the ones who have obviously had strokes, the ones who are young and robust and have their whole lives in front of them, and the ones who you wonder if you will see back here at all next week.

There are the staff, with their yellow t-shirts clearly identifying them as helpers, mentors, cleaners, folders of towels, coaches, cheerleaders, trainers, and motivators. They are quietly everywhere, making sure that things are safe, that things are clean , that everyone has access to everything they need, that everyone is caring for everyone at just the right level. They never get in your way or become intrusive, but if you want to talk, if you need a towel, or if you don't know how to use a machine, they are right there, ready to help you.

There are the ramps and the assistive devices, and the special purpose rooms and the pools and the saunas and the showers and the handicapped parking spaces and all the infrastructure that shouts "Come on in here, all of you, each and every one of you! It's easy to get in; it's easy to be part of this experience; we all love you here; there are no purposeful barriers here to keep you from being a part of us!" Everything points towards helping and assisting and including and being a part of something bigger than yourself, and helping others do that as well.

It just feels good.

Why can't the world be more like the Y?

Wordplay: You Are What You Say

2011-02-23T07:14:00.002-05:00

Some of you have heard me tell this story before, but I believe it's worth repeating. The event had a lasting, profound effect on me.

I was opening my regular mail one day and saw a little envelope. You know, one of those that looks like a thank you note. I did not recognize the handwriting, and there was no return address. Odd, I thought, not being able to immediately conjure up anything I had done lately that would merit receiving a thank you note from anybody. I opened it, read it, and read it again. I won't bore you with the exact verbiage in the note, but the gist of it was this.

You probably won't remember me. (As they gave me only their first name and the personal contact was many years ago, I indeed did not, sad to say)
I was having some severe emotional problems many years ago.
I came to see you for help, and you saw me for several sessions to work some things through.
You said one thing to me, a very profound thing, that I used then and that helped me work through my issues.
You saved my life.
Thank you for that.

Wow.

How many times in the course of our lives do we stop to think that something we do or say might actually be done or said at precisely the right time to alter someone's personal history? To save someone's life?

Before you get too caught up in klout.com or other ways to measure your self-worth today, take a minute to think about how you really influence people. Are the number of your Twitter followers or your klout scores or your Facebook friends or other measures of your influence paramount? Or is some little tweet or post or comment or kind word of encouragement coming from you going to save someone's life?

You may find out when you open a little envelope twenty years from now.

How will you change the world today?

Experiences Versus Things

2011-02-22T06:37:00.002-05:00

The Christmas retail buying season, much less the hoopla surrounding the holiday season itself, has passed. The newness has worn off of many of the things that we just had to have this past year-the shiny toys, the latest music, a copy of the movie that is sure to win best picture. Some of these things have been set off to the corner of the desk or worse yet, put up on the shelf in the closet where we'll see them late next November when we go hunting for the wrapping paper and the extra roll of clear tape. A few things, only a few, win our hearts and our minds and we keep them out and use them every few days or even every day. Those are few indeed. It takes a lot to capture, grab, and hold the fascination of the consumer in this fast paced, always-six-months-ahead marketing environment.

But what of the experiences just passed? What of the moments by the fire when it was so cold outside that you didn't even think of venturing out to do anything away from home? What of the trip to the theater to see that new movie, piling everybody in the car and buying really overpriced movie theater popcorn just because seeing a flick with the family just wouldn't be the same without it? What about the dinner that always smells so wonderful as the turkey is coming out of the oven and the stuffing's savory scent fills the whole downstairs of the house? What about waiting up to "see the ball drop" and to watch a few minutes of music from a band you've never heard of coming to you from a venue you'll never visit? And now, what about the first hints of spring in the air, the warmth that sneaks up on us just days (it seems) after we had another dusting of snow and early morning ice? What about the robins who come in small platoons, calling to each other and rifling through the pine straw and aerating the turf in the search for food? What about looking out the office window upstairs and seeing that, indeed, the old tree has spring buds on it again?

Something about the former is unsettling, driving, crazy-making. The passion for things not bought, untried, not captured, not possessed, not owned, not paraded about as trophies for the rest of the world to see.

Something about the latter is comforting, sublime, soothing, satisfying, settling. The scents of each season, the food, the gathering of friends and family, the remembrance of things past. The return of the signs of spring telling us that, yes, silly humans, you have made it through another cycle of seasons. You have another chance to awaken, use your senses, open your minds, and experience the life that you are blessed to have, but that sometimes you take for granted.

So. This year. This spring. This life.

More things? More experiences?

You decide.

Can You Hear/Call/Text/Write to/Email/Skype/Videochat/Tweet/FB Me Now?

2011-02-21T14:44:00.003-05:00

"Hit me back at this number when you get the chance."

"Tweet it."

"Facebook me."

We live in an age of communication. Fast, faster, fastest, instant. Some systems are getting so good that I feel like they know what I'm going to say before I say it. They start to send before I hit the end. I see patients via high definition pictures and computer hookups. Kids send suicide notes to their boyfriends and parents via text message. Relationships break up by SMS. Revolutions (and dictatorial regimes) live and die by Internet access, making use of Twitter and other mass communication media. We are sending millions of messages in millions of bytes over the air and down the wires and under the ocean. We are sharing and messaging and pontificating and preaching and teaching and lecturing and cajoling by every means available to us in the world that is so connected that it is in danger of having no boundaries at all any more. I can be finishing my shift at midnight and saying good morning to a colleague around the world as he starts his day. In real time. We are talking and talking and talking.

But are we communicating?

My fear is that we are slowly but surely losing the intricacies of human communication that set us apart from every other creature. Where is the touch in an email? Where is the downward glance in an SMS message? Where is the salty taste of a single tear after a comforting kiss on Skype? Where is the vocal inflection in a hastily thumbed text message?

Where is the communication?

We are at risk of becoming a very real cross between the worlds of WALL*E and the Terminator.

We know how to do so much.

We are fast forgetting how to feel.

How do you communicate with others?

Psychiatry A to Z: Unspecified

2011-02-18T08:08:00.003-05:00

It's hot. You're sweating. You're panting, resting, panting, resting.

Even though you're in a modern birthing suite, with soothing lighting and dark wood and soft linens and all the rest, you and your husband and your OB cannot escape the fact that you're here for one purpose and one purpose only. You're going to have a baby. Your first baby. No, really. Like, right now. Now! You and your husband have waited for this moment ever since you saw and heard that first little ultrasonic gray blush and whoosh that announced that another little heart had entered the world. One new little heart from your two hearts. A new life. The curtains are hung at home, the new white crib is put together, the grandparents are pacing just down the hall. The experience, though one of the most painful things you've ever been through, is perfect. Just perfect.

You look up at your husband, sweat pouring down your face. He squeezes your hand. He is excited. He is scared. He nods almost imperceptibly. One more push and it will all be over. You close your eyes, take a deep breath...then you all hear it. That one long, almost interminable moment of silence, that few seconds where your life is about to change forever. The doctor looks up at you both, sweating himself, smiling broadly, almost as happy as you, almost, and announces in a loud, confident voice, "Congratulations! You are the proud parents of an eight pound, three ounce Baby Not Otherwise Specified!"

Whaaat?

That just would not work, would it? You waited all that time, that nine months of hoping and dreaming and buying yellow things because neither of you wanted to find out if this was going to be a girl or a boy ahead of time. At this moment, the time of reckoning, the time of knowing, you want the doctor to be specific. You want him to confidently proclaim, "You're the proud parents of a bouncing baby boy. You have a son!"

The same thing holds in mental health diagnosis. Our bible, the Diagnostic and Statistical Manual, or DSM-IV-TR as you might know it today, is coming up on its official fifth revision in May 2013. We all hope that DSM-V will make things clearer, plainer and easier for patients and doctors alike to understand. We also hope that it will provide a little more sure footing when it comes to many different practitioners looking at exactly the same person with the same story and the same symptoms and all coming up with pretty much the same diagnosis and a reasonable treatment plan. We owe that to our patients and their families.

If you come to me for help and tell me about your symptoms, and my response to you is that you have a "mental disorder NOS" (not otherwise specified), I have done you little or no good. You knew that when you came to see me. I am a psychiatrist after all. I owe it to you to listen, collaborate, come up with best differential diagnosis I can, do the necessary testing to establish a logical diagnosis, and then work with you to come up with the best treatment plan we can craft to get you back in the saddle and living your life again. Sometimes, if that means I need to tell you that your nineteen year old son has a terrible illness like schizophrenia, or that your wife has a malignant brain tumor that is causing her paranoia and there is nothing that I can do short of referring you to a neurosurgeon, that can be very difficult indeed. However, knowing the truth and being able to deal with it head on, in my humble opinion, is always preferable to the anxiety of not knowing and fearing what might be.

Some news makes us deliriously happy. Some news saddens or even devastates us. Some news makes us resolute and determined to do all we can to persevere. Whether I am telling you that you are the new mother of a daughter or that your teenaged daughter needs to be treated for a Major Depressive Disorder, recurrent, severe with psychotic features DSM-IV-TR 296.34, you deserve the most specific information possible, not some unspecified mumbo jumbo.

Hold us to that as professionals. Keep our feet to the fire. Demand the details. We owe you that much.

My Compliments to the...

2011-02-17T06:00:00.001-05:00

When I thought about making a major job change in October of 2009, many things went though my mind. I thought about my safe and comfortable routine, my comfortable office, my comfortable work load, and the good and competent staff who worked with and for me. I thought about my patients, some of whom I had already been seeing for twenty years. I thought about my responsibilities to treatment plans developed, medication trials started, side effects diagnosed and managed, suicide attempts and psychotic breaks and those times when I was so privileged, and I mean this with all my heart, to see some of my patients at their absolute worst, their absolute depths of despair, only to witness them rise back up and get on with their lives again. I was so fortunate to be there to do just a little something to help some of those patients. I felt that I had helped a lot of people, but I saw this as just the natural consequences of the profession that I had chosen to pursue. After all, why else would someone go into medicine, and especially psychiatric medicine, unless they wanted to do everything in their power to help those folk who came to them with stories, heartbreak and brokenness. If nothing else, we are trained in medicine to diagnose, treat and do our best to fix things. We try very hard to do that every day.

Of course, I did make the decision to pursue a major change in job circumstances, and in February of 2010 I began seeing patients all over the state of South Carolina via telemedicine equipment. We are now working on privileges in almost thirty hospitals, and the depth and breadth of problems we encounter in any one eight or sixteen hour shift is truly amazing at times. I have seen little children who text suicide notes to their flabbergasted parents, I have seen eighty year olds who give up after the death of a spouse, and I have seen people with blood alcohol levels so high that technically they should not even be alive, much less talking to me. It is truly cutting edge, hard hitting, exciting, stimulating work, but it does have its limitations.

It is terribly isolating. Working in one room by yourself for that many hours, even when other people are in the clinic during the first part of a long shift, takes its toll. Seeing patients via high definition monitors and T1 lines and being able to focus in close enough to see muscle fasciculations or very fine tremors or to hear softly whispered responses to auditory hallucinations is truly wonderful. Unfortunately, it is not, and probably never will be, exactly the same as sitting across from someone in a consultation room in an outpatient mental health center clinic.

You know where I'm headed with this, right? About a month ago, I went back. Not full time, heavens no. I like the high tech stuff too much for that. Part time, one day per week now and maybe two soon if things work out that way. Nature abhors a vacuum, and hard working doctors abhor day-long holes in their schedules, so it was bound to happen. I'm back to seeing some of the same patients at a clinic I had covered one day per week for many years. A strange thing happened as they started to come back to see me. I started to get compliments and thank yous and little bursts of gratitude here and there that made me a little uncomfortable. After all, when I left a year ago, there were other doctors who picked up the colors and kept marching toward the faraway ridge called Mental Health. Patients were seen. Prescriptions were written. Appointments were kept. Life went on, and would have, without me there if I'd never come back at all.

My patients, and I call them that not to be possessive but to show that they do indeed matter to me a lot, were truly glad to see me come back. They wanted to work with me. They wanted me to take care of them, to help them, to teach them, and to learn from them. They had valued the relationship we had, they had felt a great loss when I left, and they were truly happy and excited when they heard I was coming back.

What more can any professional ask for? That sacred bond of trust and goodwill and caring that indeed flows both ways between patients and doctors is worth more than any high priced piece of technology that I will ever have the pleasure of using. That little spark of excitement that we both feel when we keep the therapeutic bond healthy and positive and moving forward does not have any price tag associated with it.

We both, my patients and I, know what it is truly worth.

Love the One You're With

2011-02-16T06:48:00.000-05:00

I live on the border between Georgia and South Carolina. I do a little work on some weekends covering a crisis unit on the Georgia side of the Savannah River, but most of my clinical work happens on the South Carolina side, seeing patients in almost twenty five hospital emergency rooms via telepsychiatry technology. I also cover some clinic work in Carolina as well. Most of the docs I interact with are in the SC systems, go to SC meetings and belong to SC medical organizations. I am a member of the American Psychiatric Association, and as a part of that I am signed up to be a member of a more local District Branch. In my case, since my residency is in Georgia, that's where my District membership was channeled.

There's a problem with that, though. I have long since been done with training in Georgia. I have no partners in Georgia. I do very little work in Georgia. So, when it comes time to attend continuing education meetings or business meetings in Georgia, I know few people involved. I'd much rather attend a meeting in Charleston and run into a few doctors from the mental health centers that I've visited in the past than go to Atlanta and feel very isolated.

Medicine is a social endeavor, but it can be very isolating if you do the kind of job I do most of my working hours. Membership in medical and other professional organizations can offset some of that isolation by connecting with colleagues once or twice a year for meetings, or every month or two for dinner programs or other presentations. The question is, do you align yourself with those who live in the same geographic area, or do you flock to the people you know and work with most often? Do you love the one you're with?

For me, that's an easy choice. Columbia is closer than Atlanta for large meetings, Charleston is great for winter meetings and catching up with colleagues, and I know far more doctors in the various SC systems than I could ever hope to in my "home" state. I'll be writing a letter to the District Branch soon to switch allegiance back to Carolina.

Georgia will always be on my mind, but the smiling faces and friendly places of South Carolina will always be irresistible draws for me as well.

Do you have areas of your life that call for split allegiances or put you in positions that call for tough choices?

iHurt

2011-02-15T06:44:00.001-05:00

I have been thinking a lot about pain lately. No, wait, that's not correct. I have been IN pain a lot lately. That makes it hard to think about anything else. I am not used to this. It does not make me happy. I see myself becoming a House clone, using my cane to bash unsuspecting ignorant people over the head and smiling demoniacally. When people ask me how I'm feeling today, I know they mean well, but it's really hard to tell them how this feels on a day to day basis. It hurts. Sometimes it really hurts. Sometimes it hurts like hell.

Any of you who work in clinical healthcare know that there are various scales for asking about and recording levels of pain. Some use numbers, some use smiley and frowny faces, some have you make your mark along a continuum, etc., etc. They all have their places. They all help us to document things as time goes by. But do any of them actually convey, in real time, in plain language, in graphic excellence, just where today's pain level is? I would submit that they do not.

I have a new scale for you today. I submit this to you feeling utterly confident that if you share it with others and use it religiously, that there will be virtually NO misunderstanding about your level of pain on any given day. Trust me on this. A little cross training and we're good to go.

I give you, ladies and gentleman, the iHurt scale. Like any i-device, it is simple. It is elegant. Anyone can understand it. Anyone can use it. It has no buttons. Enjoy.

0 "Beer on the deck in the sunshine." Simply put, I feel NO pain.

1 "Mosquito bite." I feel something, but I can just slap it away.

2 "PowerPoint." Dull, aching, obnoxious, never-ending.

3 "Three Alarm". Feel the burn.

4 "Psycho." Crazy, sharp, stabbing pain.

5 "Boom box." Throbbing, pulsing, pounding.

6 "Upchuck." Yep, it's that bad.

7 "Appendiserious." Take something out. Now.

8 "Labor pain." I'm done. Epidural.

9 "Nein, nein, nein!" Do NOT touch me. General anesthesia.

10 "Kid Rock." Any of you who have ever experienced a kidney stone will understand this immediately. No explanation needed. Let me die.

Try it out.

By the way, I'm at Boom box today. How about you?

Yeah, I feel your pain.

Clipboard versus Flipboard

2011-02-13T22:48:00.003-05:00

I am a psychiatrist.

I love my job(s).

I am a technology lover.

I love my MacBook, iPad, and iPhone 4.

Now, the dilemma that I need your help with.

I was covering a crisis unit this past weekend, as I do about once a month. This weekend was pretty standard-issue, in that I worked with about 14-16 patients admitted for problems from bipolar disorder to alcohol withdrawal to suicidal ideation to marital stress. I saw each patient once on Saturday and again on Sunday. New patient interviews and physical examinations (of course I can do a physical exam, what do you mean by that??) take from thirty minutes to an hour depending on severity. Follow up visits usually take ten to fifteen minutes. All documentation on this unit, at least by the physicians who cover on the weekends, is done by hand, the one exception being the ability to dictate a new H&P. I like to sit in my chair, the patient sitting across from me, looking directly at him or her as I interview them, watching for signs as well as listening for reported symptoms to best assess what is going on and how I can help. I usually have at least a rough outline of notes left by the regular treating physician or nurse practitioner to base my interview on, and I in turn will compile a list of notes from the weekend that I email back to the providers for their use on Monday morning as they start their week on the unit.

The problem?

Clipboard, (old fashioned, wood and metal clip, name in magic marker on a piece of white tape across the clip, indestructible, pen and paper based, unobtrusive as I speak with the patient, etc) OR iPad (sleek, cool, distracting ["Dude, do have Angry Birds on that thing?"], and a little harder to enter information on without being pretty obvious, at least in the moment.

I like to give my patients my full attention, and I can do that a good bit easier if I am jotting notes on a clipboard as we talk. I can do this very quickly and almost do it without looking down at times, since my note-taking sheet is the same one I've used for over twenty five years. If I use a laptop or an iPad, I have to divide my attention between the device and the patient, a compromise as I see it, and probably as they see it too. The rub here? If I jot notes on paper and want to email a nice readable typed copy to my colleagues later, I must spend more time entering that data into a device later. If I do it on the iPad during the interview or shortly thereafter, it is entered once and ready to email as soon as I get home.

This is one of the dilemmas that the availability of modern technology presents to those of us who work in various settings and locations, seeing patients of all kinds in all kinds of conditions. The trusty old clipboard is functional to a fault, unbreakable, can withstand coffee sloshes, and I can throw it in the back of my car for next time. The iPad is one cool device, lets me create gorgeous content and send data effortlessly, and I can listen to Greg Allman's new album while I work. Cool.

What do you think?

Which is better for the doctor? Which is better for the patient? I'd love to hear your opinions on this one.

Is There a Doctor in the Gym?

2011-02-12T22:31:00.002-05:00

As some of you already know, I have been having some irksome new medical problems over the last couple of months. The pain and discomfort from this new problem became so bad recently that I thought it was time to bite the bullet and go see a doctor. Yes, doctors sometimes have to go see other doctors. I know that this is a shock to you. I'll give you a little time to process this fact before I go on. Go ahead. I'll wait right here.

OK, we're back. Now, as I was saying, I called my family doctor and discussed my concerns. I then remembered a nice fellow who practices in a specialty that I figured was the right one to address what ailed me, a fellow I have known for almost thirty years since I rotated through his clinic as a medical student many years ago. I called his office, secured an appointment, and went to see him this past Wednesday. I had typed up an explanatory note about my new problem, nicely dovetailed onto a brief medical history, my allergies, current medications and other items that I thought might help him to help me. He listened attentively, asked me questions, and examined me (yes, parts of the examination did indeed cause some pain, for you masochists out there). From there he sent me around the corner and down another hallway in his office to see the nice lady who drew many, many tubes of blood from my arm and proceeded to inflict more pain by x-raying the parts of my body that were already hurting just fine, thank you, without her telling me to move them into unnatural angles and hold my breath. All this being done, I was very nicely checked out, given a return appointment for a month, and sent on my way. I had looked forward to this appointment very much, as I was really in pain and not used to being in that state for extended periods of time. I was treated kindly, with compassion, professionally, and was made to feel that the staff there, from the receptionist to the doctor, all cared about helping to make me feel better as soon as possible.

That was all good, but that's not the point of this post. The doctor told me in the office that he would call me as soon as he had a chance to review the studies obtained on Wednesday. Now, I figured that he might call on Thursday, maybe on Friday, but I didn't hold my breath. I'm a doctor, too, remember? We get busy. We get behind. We forget. We have good intentions, but sometimes we fall short of our own self-imposed goals. When I didn't get a call by the close of business on Friday, I kept taking my Tylenol Arthritis and soldiered on, knowing that he would call me when he could. After making rounds of my own today, I headed to the gym to walk on the treadmill for an hour to work the kinks out.

Eight minutes before I was to stop my workout, I looked up from a particularly loud, rocking REM song to see my doctor standing by my treadmill, dressed like me in shorts and a t-shirt. "We need to talk", he said, mincing no words. My first reaction was, of course, that he was so concerned about my lab and x-rays that he knew I was going to die soon and he had tracked me down at the gym to tell me in person, fearing that I might expire in the car on the way home and deprive him of that opportunity to personally bring me the bad tidings. Of course, that was not the case. We walked down the hall together, and he reviewed from memory my lab values, findings on film, and then reviewed treatment options. "I had your chart at home, and I was going to try to call you at home tonight, but hey, here we are."

Although I do have a problem that I will have to deal with, the fact that my doctor saw me at the gym and took the time out of his own down time to pull me aside, tell me about the tests, allay my fears, and craft a mutually acceptable plan was, well, just remarkable in this day and age. Too many people talk about how medicine is no longer personal, that doctors don't care about their patients, and that once we go home, we never think about you or your problems again until we just have to. Obviously in my case today, this was not true. I came away from this encounter knowing that my doctor cares about me and my suffering, is trying his best to figure out what is wrong with me and how he can help me, and has my best interest at heart when he makes treatment recommendations.

After my experience this week, do you think I will refer people to this man for help when they need it? You bet.

Have you had similar experiences when a healthcare provider went the extra mile to show you they cared?

Happy birthday, Mr. President

2011-02-06T16:36:00.004-05:00

In November of 2007, I took a little trip to the Ronald Reagan Presidential Library in Simi Valley, CA. Those of you who live in California, or who have been to the site, know that it is one of the most beautiful parts of our country.

Today is the Centennial Celebration of the birthday of Ronald Wilson Reagan, the fortieth president of the United States.

Happy hundredth birthday, Mr. President. You served your country well, and you left some big shoes to fill.

Psychiatry A to Z: Trauma

2011-02-05T06:52:00.002-05:00

Pop Quiz: What do these four situations have in common?

1) "OMG, my boyfriend just sent me a text message that he was breaking up with me. Can you believe that? I'm going to kill myself. That's all I can do. I'm just going to kill myself."

2) "Base, this is Unit 1. We're on the scene and have found a young male, aged seventeen. Victim was ejected from the vehicle, which appears to have traveling at a high rate of speed and could not make the curve. Strong smell of alcohol. Victim is non-responsive. Victim has massive head injuries. Victim was not wearing seat belt."

3) "We are pinned down behind the ridge. I repeat, we are pinned down behind the ridge. We are being flanked. We cannot hold. I repeat, we cannot hold. We need immediate air support." (silence)

4) "I'm callin' from th' attic of mah house. The water be risin', oh, Lord, it risin' so fast, it risin' so fast. Please, please, please....

These four scenarios, all very different from one another, are examples of traumatic situations. A text message to a young teen may make her feel that her life is over. Coming upon an accident scene where a young man has been fatally injured and could have been saved by wearing a seat belt can be devastating to even the most well-trained EMT. Serving in the armed forces and being in the middle of a hot zone with a very real chance of losing your life is the classic picture that many of us see in our mind's eye when we hear the term "post-traumatic stress". The last scenario, a frantic call for help on a dying cell phone from a hot New Orleans attic, is one that most of us, thankfully, have never had to face.

I have learned over the years that trauma is a very intimate, individual experience for all of us. What might be a minor inconvenience to me might seem insurmountable to you. The loss of a spouse after forty years of marriage might seem the end of life for a man who loved his wife dearly, but it could be a blessed relief to a woman whose forty year marriage has been a hell of abuse, alcohol, and lies.

Some things are clear. Trauma is usually an event, a situation, or an experience that you would not expect to find yourself in. It hits you out of the blue, sucks the air from you, stops your breathing, sucker punches you. Most things that we think of as traumatic are sudden, intense, and very hard for us to deal with. We deny that they are happening (being stuck in the middle of one of the worst hurricanes the Gulf Coast has ever experienced), we tell ourselves that they are reversible (the sudden death of a spouse), or we try to get a second opinion that will countermand what we already know in our gut to be the truth (a newly delivered diagnosis of metastatic and terminal cancer).

Other traumas are insidious, long-standing and injurious over time. Think of the little girl who is sexually abused by her step-father at age seven, who endures this indignity over years, marries at age sixteen and leaves home to escape the trauma, only to find herself repeating the cycle over and over again in abusive relationships as an adult. Think of the mixed race child who has one foot in each of two (or more) worlds, not really knowing who he is or where he fits in, shunned by one race and ridiculed by another. The very color of his skin and his ethnic background makes living his life a daily trauma, much of which is not even under his control.

Responses to trauma can range from acute stress reactions (shortness of breath, rapid heart rate, feeling faint, getting physically sick) to chronic means of coping (alcoholism, acting out, ongoing depression, inability to hold a job). One can pass from one way of dealing with trauma to another and back again. Avoiding dealing with the stress or the event or the abuse or whatever the initial trauma was can be devastating over time.

Have you had traumas in your life? How did you deal with them? Do you have coping techniques or skills that might be helpful to someone else?

Point of Order!

2011-02-04T12:41:00.004-05:00

It was a dark and stormy night.

The consult, like the five thousand or so our group has done over the last two years, came in with the usual history. Middle aged male. Depression. Suicidal ideation. Alcohol dependence. Multiple emergency department contacts over many years. Pretty standard fare for a telepsychiatrist. I reviewed the info, made my pre-interview notes, fired up my equipment, called the ER to let them know I was ready to see this gentleman, and sat back in my chair, legs crossed, clipboard balanced on my knee. Two minutes later, this man's gray-grizzled face, tousled hair, blue paper scrubs and multiple visible tattoos were in front of me, big as life, in stunning high definition. All that was missing was the stale smell of alcohol coming from every pore. (Although I love my job, sometimes I do miss the real thing, you know?)

"Good evening, Mr. Jones (not his real name). I'm Dr. Smith (my real name, since you already know who I am), a psychiatrist, and your ER doctor has sent me a consult. He would like me to speak with you for a few minutes if that's okay with you."

The tousled hair and grizzled cheeks, along with the head they were a part of, leaned in closer to the HD monitor on the other end of this transaction, cocked just a little to one side and trying to figure out through an alcoholic haze fueled by a blood alcohol level of four times legal how in the Sam Hill a doctor was able to talk to him over this contraption in the middle of a thunderstorm. Two seconds later, he sat back in the high backed chair, laced the fingers of both hands together behind his head, crossed his own legs, and said loudly enough that the high gain mic could have heard him from Trauma Bay 3, "Well, I'll be damned! A doctor on the television. Well, of course I'll talk to you, Little Buddy! Nothing better to do. I ain't goin' no wheres in this weather, that's for sure!" This was followed by a spittle-splattering guffaw and a ribcage-rattling coughing spell that prompted me to jot down something about checking the notes for this man's respiratory status before I made my recommendations.

Point of order!

"Little Buddy"?

Now, first of all, I don't think I bear any resemblance at all to Gilligan, and the Skipper this man certainly was not. Secondly, though he looked seventy five due to his hard drinking lifestyle, by age I had him by two years, so that didn't work. I didn't really see where Little Buddy could have possibly come from. As we say in the South, I didn't really cotton to this new title that had been imposed on me by my new patient.

Many years ago, when I was just finishing my studies to get my MD degree, the number of times people addressed me as "Dr. Smith", along with the number of beepers I carried (remember beepers?) and the number of underlings in my entourage, were all terribly important. These things meant you had arrived, by God, and people were going to sit up and take notice. Many years later, these things mean nothing. I am much more secure in what I know and don't know, what titles really mean, and what value I really bring to the table for my patients and how I go about doing that every day. All that being said, there are just a few terms that I would really appreciate not being called in professional situations. Just a few.

Little Buddy, of course, goes without saying.
Buddy is another. My Friend is sort of on the fence. When I'm called to see you nowadays, it's usually to make sure you don't go into DTs or shoot yourself with a shotgun, not to be your friend.

Old pal is another. First, I'm not old, and secondly, refer to my friend above.

Hey, man! just kind of turns me off, you know what I mean? And the sometimes heard You SOB! and similar titles are those that I would not be happy sharing with my mother, who is an old-school registered nurse.

Acceptable ways of addressing me in professional situations in my middle-aged doctoring years? Well, Dr. Smith is always nice. Doctor is okay. Doc is good, and I might even let you get by with Shrink every once in a while if I'm in a good mood. Not to my face, of course, but when you're making a referral "to my shrink". That's cool.

I only ask that a modicum of respect be accorded me as I practice the craft that allows me to help you while learning something almost every single day in the bargain. Pretty nice work when you can get it.

Now, if we put the stethoscope in the other ears, what do you like your doctors to call you? Respect cuts both ways, you know. I'd love to hear your thoughts on what you call your own doctors, and how you expect them to address you.

Drop me a comment. You can call me Doc if you'd like.

Dash Away, Dash Away, Dash Away All!

2011-02-04T07:27:00.002-05:00

dashboard |ˈda sh ˌbôrd|
noun
the panel facing the driver of a vehicle or the pilot of an aircraft, containing instruments and controls.
• historical a board of wood or leather in front of a carriage, to keep out mud.

MacBook/OS X Dictionary

I was sitting at a red light yesterday, waiting to turn right when the coast was clear. I looked up, checking the lay of the land, and I saw the dirty, dinged up white service van. You know the kind. Big hand lettered "Joe's Plumbing" on the side in black, rusty scrapes and scratches from too many swipes by too many trees on too many side roads during too many calls. The windshield was dark and grimy, but I noticed one particular thing about the inside of this van right away. The dashboard was piled high, I mean covered and smothered, with papers, invoices, Styrofoam cups, paper napkins, and all manner of trash that I couldn't make out from pistol distance. Instantly, as I am wont to do, I had this idea: What's on everybody's dashboard? Then, of course, the idea proceeded to become a metaphorical idea, like a Transformer, and became: How do we all keep our dashboards, that is, the command center of our lives, organized? Do our dashboards and our lives look like this, all paper-strewn and irresistible to geologists looking for strata long since buried and fossilized? Do we keep them swept bare, Swiffer-dusted and pristine? Are they adorned with stuff, suction cups and wires and sticky pads and such? Somewhere between red and green I answered myself. The answer is yes. And yes. And yes.

Some dashboards are like this guy's. (I must assume he was a guy, even though I could not see his face, for the sake of all that's holy) Everything that enters our life goes on the dashboard. No sorting, no screening, no organization, no filtering. Just garbage in, garbage out. Envelopes opened and tossed on the pile. Cups drunk from and discarded. Invoices written out but never mailed. (Can you say accounts recyclable?) These folks, and you know who you are, live life not on the edge, but perched on top. They sit on a pile of stuff that is so large and growing so fast that is daunting just to ponder what's in it, much less process it. So they don't. Enter Van Man.

Other dashboards are festooned with Garmins and Tom Toms and satellite radio receivers (Siriusly) and sticky pads that hold cell phones and iPhones and iPods and Zunes and all manner of small electronic gadgets. These folk feel the need to meld the world of the office and the communications bunker with real time travel. Don't get me started. Keep your phone in your purse or your pocket. Keep your eyes on the road. Live longer. Shut. Up. I don't want to hear it. (Yes, I'm talking to myself again. I really need to go back to get my medication checked soon.)

Still other dashboards have hanging plush dice and bobble heads and air vent air fresheners and streamers and extended view mirrors and outside temperature sensors. What can I say about these in-vehicle expressions of one's need to smell better, see where you've been and not watch where you're going and see how far the NFL mascot will bend over as you round that next mountain curve doing seventy. Nothing. So I won't. Nothing to see here. Move along.

Finally, a few dashboards are pristine. Big word that means clean, unspoiled, even primitive. Not a piece of paper. Not one electronic gadget. Not a vanilla-latte-flavored smelly thingy hanging from the mirror. Clean. Unobstructed. Providing an excellent view of what's coming up. Looking forward to where the vehicle is actually going and actually enjoying what is whizzing by outside during the trip. Oh, my God, what a concept! To think that we may actually enjoy the journey in the car and in real life in real time without the noisy distractions that someone says we have to have with us at all times in all places on all days forever more amen.

I can get in my car and drive it somewhere. I can engage my own life and live it. Simple. Elegant. Scary. Possible. Necessary.

Wait. I'm verklempt.

Please, talk amongst yourselves. The topic: clearing the dash.

Discuss.

This Ain't Your Mama's Manic Depression-Part 11

2011-01-17T16:17:00.002-05:00

Ah, the new year. 2011. A new beginning. Well, not exactly. We have to finish up this series first, and then we'll move along to something else. Yes, I am sometimes a slacker.

Bipolar Disorder. The future. What does it hold?

As I mentioned before, never count out therapies that may be considered old school by some even today. Psychotherapy, yes, good old sitting down and talking to a skilled counselor or therapist or even psychiatrist (yes, can you believe we were all once trained to do fifty minute hour psychotherapy and most of us actually enjoyed doing it?) can work wonders, especially if you spend most of your clinically debilitated time in the depressive phase and can't or do not choose to make medication the cornerstone of your treatment plan. Yes, there are many of you out there who fit into this group and who do very well indeed with the ongoing follow up plan for managing your illness that you and your provider have crafted over the years. Bravo! Keep going!

You may have read about or heard about light therapy or light boxes. Now, some of my friends and associates who call the great frozen north lands home swear by these, especially in climes that really do see a remarkable decrease in total hours of natural light for much of the year. There is some evidence that they work, much of it anecdotal, and there is a very particular way that you must use these devices in order to get any benefit from them and to make it last, which is obviously important in your ongoing good mental health. Again, you've heard me say this before. Find a trusted partner, discuss your treatment options, and if this is one that looks like it will fit in your plan, go for it.

Other treatment options that you might hear about include sleep deprivation, thyroid supplementation, stimulant use, vagus nerve stimulation, electroconvulsive therapy (ECT or "shock treatments"), and TMS (transcranial magnetic stimulation). Once again, keep your eyes and ears open for good studies that show whether these treatments actually have efficacy or not. Sometimes the weirdest things (injecting urine into guinea pigs) gives us our best and most reliable treatments in the long run!

What else is on the horizon. Well, we already know that things like cranial blood flow are being looked at through things like PET and SPECT scans, and we're looking to see if there are differences of chemicals across brain regions. The genetics of bipolar disorder, as in all psychiatric disorders, is fascinating. Family trees are often laden with the fruit of not just illness and pathology but resilience and successful treatment. That family history can be a gold mine when trying to figure out the best treatment for a particular individual. New computer models and new pharmaceuticals are always in the pipeline (controversies aside, as they are always with us, it seems) and lead the way in the research and academic sectors.

My best parting advice to anyone looking to better understand and deal with bipolar illness today?

1) Learn all you can about it. If you receive that diagnosis, don't deny it. Embrace it. Learn and participate fully in your treatment.

2) Apply the knowledge you gain to your own symptoms, not to the examples in the book. YOU (not your spouse or your sister or your doctor) know you better than anyone else. Listen to your body and your mind and to what they tell you. Apply what you learn and live!

3) Best practice treatments lead to recovery. Don't be afraid to try new things, but remember that things that have been tried, tested and have worked for a controlled group of people, AND that have been replicated over time, are the most likely to help you in the long run. Sometimes the newest, most expensive, most glitzy and exciting treatment is NOT the best for you.

I hope you have enjoyed this eleven part series, This Ain't Your Mama's Manic Depression. I welcome your comments.

Something new is always around the corner at Shrink Rapping, so check back in a little while for more. In the mean time, live healthy, live happy, and have a great 2011!

This Ain't Your Mama's Manic Depression: Part 10

2010-12-29T07:17:00.002-05:00

When I left you last, the Allies had established a beachhead at Normandy.....oh, wait, that's my other blog. Sorry.

Part 10 of Yo Mama. That's where I am, right? Yes! We're going to wrap this thing up before the end of the year and move on to parts unknown. Today, we touch on treatment issues. Quick and dirty. I know you have New Year celebrations to plan. Hang on. Here we go.

So, we have established a diagnosis of bipolar disorder. You have told someone, or someone has told you, that you have this disorder. Now what? Do you ignore it? Many people do. Do you wing it? Many people do that too. Do you let your family doctor treat you? If he will, bless his heart, then of course, if that is a mutually agreeable solution of both of you. Do you go see a psychiatrist along with a counselor or other mental health provider. That works too. Do you see an evolving pattern here, my friends? I don't care where you go or who you see. I only care that you get treatment. Real treatment that keeps you functioning at your best and fully participating in your own life. Yes! That's the key!

Treatment. Now, first off let me tell you that all treatment for bipolar disorder is not drugs. I happen to do a lot of medically based treatment that involves recommending or prescribing medications, and I'll touch on that presently, but other forms of mental health treatment apply here as well. Individual counseling in all its flavors helps to deal with issues old and new. Couples or family counseling may help to iron out problems between people who are affected by the outgoing ripples of this disorder. Outpatient or inpatient treatment, voluntary and involuntary, may be needed as we've touched on before. Once again, get what you need. Seek it out. Ask for it.

Medications are excellent to deal with specific symptom types or clusters. Anger, mood swings, irritability, depression, mania, energy changes, sleep problems, all are a part of the changing landscape that is bipolar disorder. As I tell my patients, many people do not "read the book". In other words, they do not come in with neatly typed out lists of symptoms on neatly spaced time lines that lead to neat and tidy diagnosis. They come in and tell me what is wrong for them, what is giving them problems. Their specific symptoms are what we target, not the symptoms that are written down in the DSM-IV-TR.

So what medications are you likely to see in your journey through treatment of bipolar disorder? Lithium, Tegretol and Depakote have been the Big Three of bipolar treatment for some time now. You remember the picture of them sitting there at Yalta, dressed in overcoats against the cold, one in a hat, one with a cigar? Oh, maybe not...

Anyway, lithium, though an old drug, is still quite good for "classic" bipolar patterns and symptoms, that is the usually expected mania and depression alternating with each other in some regular fashion. I have patients tell me all the time that they do not want to take that "crazy drug" because they think of Jack Nicholson and psych hospitals and ECT when they hear lithium and they get scared. It is a fine drug, it is very cheap (excellent in this time of economic crisis) and it has a large quantity of literature behind it that says it works. If lithium comes up in the conversation, at least consider it.

Tegretol and Depakote are anticonvulsants that also happen to be used in psychiatry, Once again, they are good drugs that work best in specific cases and for specific symptom clusters. They have their own set of side effects, some of which might lead to discontinuation. If I put a young woman on Depakote and she gets swelling in her ankles and weight gain and her hair starts to thin, do you think she's going to be pleased with her treatment or with me? Nah. We start over. Other antileptic drugs such as Lamictal have also been used with good results.

Older drugs are usually cheaper. Brand name or new drugs are usually more expensive. I prescribe both. Remember that newer, flashier and more expensive does not always mean better. The cheapest lithium prescription at pennies a pill may give you as much control over pesky symptoms as a prescription of a new atypical antipsychotic that costs hundreds of dollars a month. Work with your provider to figure out what is best for you. If you cannot afford the medication, the doctor visits and the lab tests that need to be done to stay on the treatment, you won't stay on the treatment, and what happens next? You relapse.

Finally, there are medications that I might recommend for you in the ED during an acute phase or crisis in your clinical course that I would not want to have you keep taking for the long run, or maintenance phase, of treatment. Each phase is different, and each has varied needs. Your provider will talk with you about these phases of the disorder and its treatment and what your goals are for each. Participate fully in this discussion. It's your life!

In Part 11, we'll wrap up by looking ahead, which is what you always do at this time of the year, yes? We'll touch briefly on some of the things that are on the horizon for the diagnosis and treatment of bipolar disorder and other mental illnesses. Then we'll kick back, think about 2010, and get ready to welcome 2011. I trust that it will be a healthy and happy year for all of you as work with those who have mental illnesses, or struggle with them yourselves.

See you right back here soon for This Ain't Your Mama's Manic Depression: Part 11 (The Terminator)

Have a great day!

Today's Post is Brought to You by the Letter F

2010-12-28T07:13:00.002-05:00

fatigue |fəˈtēg|
noun
1 extreme tiredness, typically resulting from mental or physical exertion or illness : he was nearly dead with fatigue.
• a reduction in the efficiency of a muscle or organ after prolonged activity.

....from my trusty MacBook dictionary...

No, this post is not a part of my twenty six installment Psychiatry A to Z series. You'll have to wait for the next one in that group, which by the way will be looking at a "T" word. This one concerns a word that starts with the letter "F", and it is a subject that has been weighing on my heart and mind for some time now. We are talking about fatigue here. Being dead tired. Zonked. Out of it. Exhausted. I wonder how you feel about it, especially those of you who read my blog and are either doctors or patients (or both in some cases) yourselves.

I am a psychiatrist working three different jobs, out of both love for what I do and a need for enough income to support my family the way I'd like to. (Psychiatrists are usually listed just above primary care physicians and pediatricians on the doctor pay scale. You don't usually become a shrink, especially one who works in the public sector, to get rich. Yes, believe it.) One of these jobs is a telepsychiatry position that often requires that I work sixteen hour shifts, usually from eight in the morning to midnight. I find that I am most productive and sharp early in the shift, which would be expected I suppose, and that I must try harder to keep myself focused and sharp as the evening wears on. This is clinically significant in this study with an "n" of one, in that a lot of psychiatric patients show up in crisis in emergency rooms from about four in the afternoon until well into the night. I am not allowed to nap or sleep on the job, so for now a "strategic nap" is not possible. Coffee helps, but that's another story for another day, isn't it?

My family and friends have had several discussions over the last year or two on the changing "rules of engagement" for today's interns and residents as compared with how we "old farts" trained (I am fifty three years old). Of course, we were all trained to work hard, work long hours, and not complain. It was part of the training and the job that was welcomed as we became doctors. I'm aware of the studies that look at degrading performance over time, but I'm also well aware personally of how grueling, long, tedious, difficult hours and situations build character, competence and ability under stress. I think it's important to look at both sides of the issue and come up with the best solution that works in the service of the physicians of tomorrow as well as patient safety.

What do you think? Should doctors be like workers on factory assembly lines, doing just a few jobs repetitively and well but for shorter, limited amounts of time? Should they be allowed to take twenty minute power naps when working long shifts? Should they be allowed to choose to "work doubles' and stay over for an extra shift if they want to do so for more experience or more income? If a doctor is driven to work long hours and busy schedules and chooses to do so, does this really pose a risk or danger to his patients?

Please let me know how you feel about this issue. I know you have thoughts on this one!

Psychiatry A to Z: Sadness

2010-12-27T12:01:00.003-05:00

You have just told a friend of yours that your transmission fell out of your car, your furnace is not working and it's seventeen degrees outside, and you have been told that after the New Year you may be downsized. You're feeling a little blue about this general turn of events. You tell her that too.

"Well, of course. You're depressed! Who wouldn't be with all that going on?" Your friend means well, of course. The problem is, she is confusing two common and similar states of mind, sadness and depression. We'll focus on the former if that's okay with everybody.

This holiday season has been a strange one for me emotionally. I love Christmas and everything about it, from the church services with incense to the baking of cookies (well, the eating of cookies that others have baked, in my case) to the giving of gifts to watching movies late at night while sipping a hot drink. I love it all. Unfortunately, our family has had to weather two major losses this season that have left us reeling a bit as we try to celebrate as usual. For me, this has meant rolling waves of sadness. Not depression. I am not depressed. I am happy that it is Christmas and that the new year is coming. Seeing 1-1-11 looming on the calendar just looks a little magical to me and energizes me just a bit. There has to be something special about a year that starts with 1-1-11. My granddaughter's second birthday will come this year on 11-11-11. How cool is that? No, I am not depressed, but at times I am sad.

Sadness slows us down a bit, leaves us pensive, makes us re-evaluate things, and takes the air out of our lungs. It sucker punches us. It darkens the light and makes the sweetness a little less intense. It dims the brightness. It dials down the joy.

Sadness, like happiness, is a normal state of mind. It is a necessary state of mind. One must feel sadness sometimes so that one knows how truly wonderful happiness is. It is not bad or wrong to feel sad, or to share that feeling with someone you love. Please, this holiday season, don't bottle your sadness and put it on an emotional shelf, hoping to get it down and pour it out a few drops at a time sometime next year. Savor the sad moments just as you do the happy ones. Tell stories, remember, share, grieve, cry, think. Process this emotion. Use it to make you more human and stronger coming out than when you went into it.

While some of you, like me, may be transiently sad this season, I wish you nothing but the best in 2011. We will have our happy, delirious, wonderful mountaintop moments in the coming year, and we will walk through valleys out of necessity. We will be as strong as we can through it all, and we will be all the wiser come 2012.

One more thing. There is another definition of the word sadness that I thought was very interesting indeed, in light of all the baking going on around my house this holiday season. Sad, with respect to dough, may mean "heavy through having failed to rise".

When you are sad, never fail to own it, feel it, process it, and rise again to move forward toward the happiness that you know waits just around the corner, or at the next flip of the calendar page.

Happy New Year to you all.

One more thing...

2010-12-21T12:00:00.001-05:00

OK, yesterday I gave you homework for this week leading up to Christmas. Have you baked your cookies yet? Watched that movie? Thought about a new holiday tradition for you and your family this year? Keep working! You've got plenty of time.

There is just one more thing I wanted to get you to think about as you ice those cookies. You know that as soon as Santa's last reindeer lifts off the last roof and heads back to the North Pole, we will start to see commercials about New Year's resolutions. Now, I don't have to tell you that almost everybody makes them and virtually nobody keeps them, at least not longer than a few weeks at best, right? So, now that I've given you a leg up on the holiday happiness thing, I'm not going to follow that with demands that you lose fifteen pounds or stop biting your fingernails. I don't want you to give up anything for me, or for yourself.

What I would ask you to do as we slide into 2011 is to think about one thing that you want to keep doing all next year. Better yet, what is one thing about you that you want to improve upon, grow, or add to in 2011? Are you a good listener? Do you sing? Are you good at coaching little kids on the baseball field? Are you the patient type who is a master at teaching adults to read? What is it about you that you are proud of and want to utilize more next year?

I challenge all of my readers to find one thing that they will work on, improve, and do even better in 2011. I'd love to hear what you decide to focus on next year.

Who says a New Year's resolution can't be fun, right?

Happy New Year to you and yours.

These Three Things

2010-12-20T16:02:00.002-05:00

"I hate this time of year. I always have. I just want to go to bed, pull the covers up over my head, close the shades, turn out all the lights, and when I wake up I want it to be January 2. I want to skip the holidays! I hate..."

STOP!

I am not going to listen to this from any of you again this year. I'm just not. We're done with the negative, whining, oh woe is me stuff in 2010, okay? I know, I know. You look up at your big paper calendar on the wall (because you are one of the wonderful souls who still love to keep a paper calendar and strike through each day as it goes by in fine pencil, black pen, or bold red Sharpie depending on your mood) and you see that big red 25 there and you freak. Because of that one day, you FREAK. No, we're not doing that this year. Come along, hold my hand, walk this way, open your eyes. I'm not going to platitudinize. No, that does NOT have anything to do with a small, duck-billed mammal that is God's sense of humor incarnate. It means I'm not going to tell you to sit around a Christmas camp fire and sing kumbaya. I'm going to give you some homework. Three assignments, actually. I want you to do all three and I DEFY you stay sad, cranky and miserable after doing them. I don't care how silly you think they are (or I am) or how foolish you feel doing them. DO THEM.

Number 1: Bake a batch of cookies.

Oh, yeah, right, cookies. How sweet is that? Geez. Wait, wait, there's a method to my madness. You cannot break hunks off the supermarket cookie log that's been in your fridge for three months and sling them into the oven. You can use said roll of dough, but you must fashion each cookie individually. Make reindeer, toy soldiers, little tin drums or dragons from Avatar. I don't care. Be creative. Decorate the suckers. Sprinkle them. Frost them. Color them. Tell stories about them. Make a mess. Let the mess sit for an hour or two before you clean it up. Oh, and one more thing. You CANNOT do this alone. Let your spouse help. Invite your kids to look up from their phones long enough to dig out some frosting. That little old lady who lives next door? Either invite her over to help or take her some when you're done.

Number 2: Watch It's a Wonderful Life.

I know many of you have already seen this classic Jimmy Stewart movie, but I'll bet my last cookie (it's a small replica of the USS Enterprise) that a few of you never have. It's a great old flick that I never get tired of. If you get all the way through this movie and still feel that your life is meaningless and that nobody would miss you if you'd never been around, then go back and bake another batch of cookies and try this again. Bonus question for this round: "Every time a bell rings, ________________________."

Number 3: Start your very own holiday tradition.

Now, you might tell me once again that this is trite and silly and that it's not worth your time to come up with a tradition, yada yada yada. Listen to me. We have a tradition that we started in my family sixteen years ago this Christmas. It involves giving a super secret gift to one family member each year and nobody but me knows the details until the last gift (this one) is opened on Christmas morning. Easy to do? Yes. Simple to plan and prepare for year after year? Check. Wonderful for building anticipation and joy? Absolutely. I hope my family continues to do it long after I've watched my last Christmas movie. Your tradition can be anything you want it to be. It can be a private one, but I'll give you the same hint I've already given you once before. If you involve other people, your holiday will be that much brighter for having done so.

So that's it. Three homework assignments for you to do between now and Christmas. You are smart. You are creative. You are resourceful. You have five days.

What are you waiting for?

Happy holidays!

Psychiatry A to Z: Resilience

2010-12-19T21:00:00.000-05:00

"Resilience is accepting your new reality, even if it's less good than the one you had before. You can fight it, you can do nothing but scream about what you've lost, or you can accept that and try to put together something that's good." - Elizabeth Edwards

This post, given the news this past week of the death of Elizabeth Edwards, was an easy one to pick. The choice of an "R" word was made for me.

Resilience, according to my trusty MacBook dictionary, dates back to the mid 17th century and comes from the Latin resilient- ‘leaping back,’ from the verb resilire (see resile ). There seems to be another story every day, coming at us from all angles, about someone who feels slighted, entitled, hurt, bruised, injured, and put down. They cry foul, they make excuses, and they demand compensation, nay, even damages for all that has unjustly befallen them. In this context, in this world of "what's in it for me", do we really still find resilience? Yes, Virginia, there is a character clause.

Resilience is the father who doesn't complain that he has lost his high paying corporate job, but learns a new skill and markets himself, landing two new jobs in the bargain and taking care of his family.

Resilience is the mother who doesn't stand in line to get a handout, but who takes in children and babysits, providing a needed service to her community while making Christmas money for her own children in the bargain.

Resilience is the man with diseased hip joints who can no longer play golf, but who learns that he has a talent for painting that he never dreamed he had.

Resilience is the depressed young man, dependent on narcotics, sorry for himself when he has to move back in with his mother, until he learns that she has been diagnosed with terminal cancer and he knows that he is now living there for a reason.

Yes, we can whine and scream and point fingers and blame others or even blame God for our conditions and our run of bad luck. We can do that, or we can accept our new reality, embrace it, and put together something good.

Thank you, Mrs. Edwards, for giving us this most wonderful, timely Christmas present this year. Your strength, courage, and resilience in the face of all you faced are shining examples for us all. I hope we can receive them and use them all year long.

This Ain't Your Mama's Manic Depression- Part 9

2010-12-16T09:18:00.001-05:00

So, what does it take to evaluate someone for the diagnosis of bipolar disorder?

I hate to be trite, but first, it takes doing a good diagnostic evaluation! I have been surprised and amazed through the years that folks come to me saying that "my doctor told me I have a touch of bipolar" or "I think I may be just a little on the manic side sometimes". Now, having a touch of bipolar is something akin to being a little pregnant. Being a little on the manic side may be apropos of the last nine shopping days before Christmas, but it's not very helpful when trying to nail down a mental health diagnosis that might have lifelong consequences. So, what does a diagnostic evaluation include?

One of the things that I like about psychiatry is that we are able to use our ears, our eyes, our brains, and occasionally our mouths if that's appropriate. (It's usually a lot more helpful to listen that it is to talk) We interview patients to elicit historical information about symptoms, timelines, family history, use of alcohol and other substances, sleep and appetite patterns, energy level fluctuations, and psychotic symptoms like hallucinations. We watch how people walk, talk, move, sit, stand, and respond with physical clues and cues. I have been able to come up with a pretty good working differential diagnosis for patients who could not say a word to me but were obviously having abnormal involuntary movements, tremors, grimacing, "silent seizures", or gait disturbance. We also look for medical causes of "mental" illnesses, utilizing lab values, x-rays, CT scanning, MRIs and other gee-whiz technology to get to the bottom of a problem. Again, I have seen more than one case of thyroid disease present as severe depression or pulmonary embolism showing up as severe anxiety and agitation.To put it succinctly, everything that hallucinates is not schizophrenia.

Once the correct diagnosis is made, no small feat, then there are other issues that are very important depending on the setting. Safety is paramount, both for the person being evaluated, their significant others or family members, and the person doing the evaluating. Outpatient counseling or therapy may be indicated, medications might be helpful, a brief inpatient hospital stay might be next on the agenda, or involuntary commitment might be needed in some cases to prevent harm to self or others.

No matter the setting, no matter the level of restriction or safety that must be maintained, establishing a therapeutic alliance is very important. In simple terms, you and I must get along reasonably well and see eye to eye on what you need and how I can help you, or nothing much is going to get done. This alliance can be established even when severe manic symptoms or overt psychosis is present. I have had some of the most meaningful therapeutic engagements of my professional career with patients after a terribly severe episode of dyscontrol that left them feeling vulnerable, embarrassed, and broken turned into a stepping stone for positive, lasting change for the better.

Finally, education is as important as anything else we do. I always tell people that nurses and nurse practitioners do a much better job at this than any doctor I've ever known, as their training is often geared towards education and prevention. I have asked patients about their diagnoses and treatments before in my initial interviews and had them stare blankly back at me, not able to tell me a thing about what they have been treated for and why. Can you imagine what it would be like if that happened after someone had been diagnosed with a brain tumor or seizures or a stroke? Mental illness need not be shrouded in mystery. If you are diagnosed with an illness, you should learn all you can about it, understand it, and participate fully in the treatment prescribed for you.

Next up, we'll look a little more closely at some of the more common treatments for bipolar disorder today. Check back right here for This Ain't Your Mama's Manic Depression- Part 10 soon.

This Ain't Your Mama's Manic Depression- Part 8

2010-12-03T15:27:00.002-05:00

There are lots of problems caused by bipolar disorder, but one of them is a real killer. Actually, it is a killer over thirty thousand times each year in the United States alone. Bipolar disorder, left unchecked and untreated, can lead to suicide attempts and completed suicides at an alarmingly high rate. There is a 25-50% lifetime risk of a suicide attempt in those diagnosed with bipolar disorder. As many as 15% of these patients will die by their own hands, with many, many more making unsuccessful attempts. This is one of the most important reasons that this disorder needs to be screened for, diagnosed, and treated appropriately.

Are there special or specific populations where bipolar disorder tends to rear its head? Yes!

More and more children are being diagnosed with this disorder early on. Now, before you start to rant that we over-diagnose and over-treat children, let me tell you that IF a child has a very strong family history and IF that same child is evidencing symptoms of illness that are diagnosable, starting treatment early may save him many years of suffering and morbidity, or even hospital admissions and suicide attempts. The disorder is sometimes hard to spot in kids, who tend to present with irritability and not the classic "happy" manic picture. Destructive outbursts, physical complaints and trouble with grades and school work may be heralds of problems in this age group.

Women who have a tendency to this disorder may present with their first symptoms or episode during pregnancy or especially in the post-partum period. The correct diagnosis may not be made or may be delayed because most everyone has heard of and expects to see some form of the "baby blues" after delivery, and may dismiss worsening irritability or depression as a normal part of the post delivery process. This can be debilitating or even fatal.

What about the elderly? This is a very fast growing segment of our population, and age does not protect against an overt manic or depressive episode. Most patients will have been diagnosed with the disorder decades before they reach their twilight years, but not always. Also, alcohol and drug use in the elderly, sometimes ignored or kept quietly hidden away, may mask ongoing problems with mood disorders in this senior group.

Substance abuse and dependence in any age group may complicate the timely diagnosis and treatment of bipolar disorder. My rule of thumb has always been that if I see one of these, I need to make sure I ask probing questions about the other one. Otherwise, I am likely to miss it. Other so called "dual diagnoses" may also include mental retardation or other developmental delays that do not in and of themselves preclude the diagnosis of bipolar disorders.

Next, we'll look at current diagnostic and treatment considerations as endorsed by the American Psychiatric Association. See you right back here for This Ain't Your Mama's Manic Depression- Part 9.

This Ain't Your Mama's Manic Depression- Part 7

2010-12-02T23:20:00.003-05:00

In the year of my birth, 1957, a momentous time indeed, Swiss psychiatrist Roland Kuhn found that there was a way to treat depression that we still sometimes use today. He found that the drug Imipramine could indeed treat the blah side of this disorder. But...whoopsee...it could also cause those with the propensity to switch into mania to do so with dispatch. One of the upsides to this upside down mess? The distinction between unipolar and bipolar depression had been made, and with it the modern age of psychiatry had begun. Exciting stuff! Well, it was. Really!

In the 1980s, "Bipolar Disorder" replaced manic-depressive disorder as a diagnostic term in the DSM III. The differences between childhood onset and adult bipolar disorders were also looked into starting at this time. Yes, I know I passed the '60s and '70s, but really, I didn't want to embarrass you-I knew you wouldn't remember those two decades anyway. Another blog post for another day, that one...

How is bipolar disorder classified today, in the DSM IV-TR?

Bipolar I Disorder: manic, hypomanic, or mixed episode with or without MDE (major depressive episode)
Bipolar II Disorder: MDE recurrent and hypomania but without manic episode
Cyclothymic Disorder: Two year period of hypomanic and depressive symptoms with no major mood episode
Bipolar Disorder NOS: bipolar features but not meeting specific criteria

(Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Rev. Washington, DC: American Psychiatric Association; 2000.)

Two to three per cent of the population suffers from some sort of bipolar disorder. Gender distribution is equally likely, and there does indeed seem to be a genetic component to how this disease is passed down. No, I did NOT just give you permission to blame your criminal record on your mother. Bipolar disorder is the sixth leading cause of disability worldwide.

36% of sufferers did not seek treatment of any kind until ten years after their symptoms began. (NDMDA survey, Hospital and Community Psychiatry 44, No. 8 (1993): 800-801). This means that many people are walking, talking textbook examples of what bipolar disorder does to people and they do not even know it! Imagine the suffering that can go on in ten years' time, and all for no reason.

In this same survey, the average respondent had seen 3.3 physicians before the correct diagnosis was made. I guess the first two guys were just not on the ball, but the third guy we can let slide. I mean, what if he was only using the middle third of his body? He may have been the only one of the three who had a gut feeling about the diagnosis. Maybe he was the one who was right!

There are lots of problems caused by bipolar disorder, but one of them is a real killer. Actually, it is a killer over thirty thousand times each year in the United States alone. Meet me right back here for This Ain't Your Mama's Manic Depression- Part 8, and we'll discuss. See you then.

Psychiatry A to Z: Questions?

2010-11-30T22:23:00.002-05:00

How many times have you been to the doctor and had your ten minute appointment end something like this?

You: "OK. I guess I can try that medicine for a while and see if that gets rid of it."

Doc: "Great. I'll set you up for a follow up in about ten days, OK? (Looking at his watch and standing up, heading for the door, hand on knob). Any questions? (Halfway out the door, not really expecting or wanting to hear a response from you). Good! See you in ten days then."

How did that make you feel? (God, what a shrinkified question that is, but it's from the heart and very serious). My guess is that you thought the list of questions you had already prepared and wanted to discuss with the doctor (and that he certainly knew you had with you, oh yessir) was not really that important to him. I also surmise that you felt that the doctor did not have the time to really address your small concerns, and that made you a little worried about what he would do if you had a major problem pop up in your next ten minute appointment. Lastly, I wonder how valued you felt as a person. Did your doctor really look at you as his partner in helping you to get well, or is he still in that passive information dispensing mode that many of us tend to fall back on when we're pressed for time and running behind? Well, let's cut to the chase here, shall we? I'm going to let you in on a few little secrets about questions and doctors.

1) You should always think about questions you have for your doctor well before your appointment. Write them down. Put them in order of importance, most pressing concern at the very top. When you get to the office, tell the doc first thing that you have some questions to ask him and that you very much want to make time to cover them before you leave.

2) No question is stupid or crazy or too simple or too elementary. Anything that you are concerned about and need to get your doctor's opinion about is fair game. That's why we spent so many years in school and training, and that's why we must still get many hours of continuing medical education every year to keep our licenses. We need to know stuff so that we can provide better healthcare for you! Nothing that I learn should be kept a secret from you.

3) If you've researched some possible answers to your questions ahead of time and want to share what you found with your doctor, have at it. Bring a reference, or better yet, bring the article or the paper you read. If your doctor really cares about you as a person, values your input and your preferences, and practices what we call shared decision making, he will be more than happy to take your findings into consideration. Now, that doesn't mean that he will always be able to sit right there with you and read that whole ninety-nine page journal article you scooped him on (It did just come out yesterday, after all...) during your ten minute appointment, but he may very well take it with him and read it by the fire with a nice glass of chardonnay later on that evening.

4) You deserve to get timely, reasonable answers to legitimate questions. Now, I'll tell you a little secret. When doctors feel that patients or family members are trying to "one up" them and catch them lacking or embarrass them, they do not take kindly to that. Would you? Doctors, really good doctors, want to do everything they can to help you and see you get back to health. They're not playing games with you or your treatment. They want to work with you as partners and get to the bottom of symptoms, diagnose disease, find excellent treatments, and get you well and on your way. You should expect no less. If you feel that your doctor is not treating you this way, then I would be looking for another doctor. Soon.

One last thing. Questions go both ways. You have questions for your doctor. Your doctor has questions for you. Answer them. Honestly. As completely as you can. This partnership thing goes both ways too, you know? The more legitimate information your doctor has about you, the better equipped he will be to help you get well. Just sayin'.

Any questions?

This Ain't Your Mama's Manic Depression- Part 6

2010-11-18T07:02:00.003-05:00

It was the 1940s and 1950s, a time when WWII raged on and housewives were told that their husband's shirt collars were not clean and bright enough. During this period, most patients who were loud, excitable, and agitated did not receive a diagnosis of manic depression or bipolar disorder, but were labeled with something severe and sometimes dead wrong: schizophrenia. Bipolar disorder was rarely seen any more. Did it disappear under a Hogwarts invisibility cloak? Did it go back to the future? Methinks not.

In the 1950s Danish psychiatrist Morgans Schou revisited Cade’s discovery and did more extensive clinical trials. He was a smart guy. No holier than Schou attitude, but nonetheless he did go a little further with specific recommendations for doses of lithium that might really help treat symptoms of mood disorder. He targeted measurable blood levels of 0.5-0.8 meq/L (I know, I know, your eyes are glazing over...) and found that lithium had a demonstrable efficacious effect in the treatment of bipolar disorder. You like all those big fancy scientific medical words? Nah, me neither. What I meant was, IT WORKED! He also found one more really important thing that we shrinks still think is pretty impressive. Lithium could prevent future episodes of severe mood change that were often the hallmark of bipolar disorder. So, in true Hallmark fashion, when you only cared to use the very best, you could use lithium.

Are there any downsides to this miraculous story? Well, of course, there are, Ollie. Lithium works well, but it is not a speed demon. Treatment with lithium is a distance race, not a sprint event. It might take anywhere from two to six weeks or longer for it to get in there and have its full effect. if you decide to use it, you must be aware (and tell your patients or your loved one whom you are trying to support in this whole treatment thing) that they MUST keep taking it every single day in order for it to help them. Lithium is cleared very quickly through your kidneys, sort of like Bud Lite through a college student on game day, so if you miss even one dose your blood levels fall like Obama's approval ratings after the midterm elections.

Other side effects? Gastrointestinal upset (see reference to college student above and call housekeeping stat), weight gain (severe enough at times to drive your female patients to break your fingers or cut your tires), tremors, and cognitive changes in some patients. Lithium also has what's known as a very narrow therapeutic window. This means that the blood level that works very well to keep your mood stable is uncomfortably close to the blood level that keeps you permanently stable, that is, dead. Intentional overdoses of lithium can be bad boys, requiring nasty things like dialysis to remove what then becomes not a friendly therapeutic medicine but a life threatening toxin.

If you want to take lithium, you need to get over your fear of needles. You MUST learn to knit, crochet, or do fine embroidery. No, wait, I got off track there. Not that kind of needles. You will have to visit the lab vampires, fairly frequently at first, less so later in the course of treatment, for blood levels, renal function tests, and thyroid testing. Kidneys and thyroid gland can be affected by this treatment, and you can't treat a fever if you don't check a temperature. If you really don't want to get your blood drawn or you flat out refuse to, then just look for another treatment. Don't start treatment with lithium.

Finally, lithium therapy works in about 40-50% of patients. That's ALL, you say, incredulously? Well, yeah, but none of the modern day drug therapies we have in psychiatry work for everybody, dude. The folks who tend to get the most bang for the buck with lithium are those with "classic" mania, that high, giggly, giddy kind of mania that is easy to spot at fifty paces. Those with rapid cycling, atypical mood changes and the like jut don't do as well with this drug.

In part seven, we move on to the flip side of the bipolar coin, depression. It's harder to treat over the long term, a bigger slice of the overall clinical pie, and more debilitating for a lot of folks than mania. Never fear! In the year of my birth, 1957, a momentous time indeed, Swiss psychiatrist Roland Kuhn found that there was a way to treat depression that we still sometimes use today.

I'll meet you back right here and we'll talk about it in This Ain't Your Mama's Manic Depression, Part 7.

Psychiatry A to Z: Pity

2010-11-17T08:06:00.002-05:00

Let's set the scene, shall we?

You're driving along the road and you look over to the right shoulder as you stop at an intersection. There is a man there, sitting on an upside down pickle barrel, with his hat pulled down over his eyes. His clothes carry the grime of two months, and he can count no bar of soap in his list of close friends. He wears gloves with the fingertips cut out. His graying beard was probably a rich chestnut brown at one time, but now it's the color of a rusty gun barrel.

You can't tell if he's asleep, but his head nods up and down almost imperceptibly. When a horn honks behind you, he jerks into an upright state of alertness. His lips are moving. Mumbling, mumbling, smiling, grimacing, mumbling. It wouldn't matter if your window was down-you would not be able to catch what he is saying or make sense of it. Chances are, he has some kind of mental illness. Maybe not, but the chances are good. On his lap, you see the small cardboard sign that makes you wish the lights were timed to change just a little bit faster. Scrawled in what appears to be black crayon are the words that are always there. Homeless. Will work for food.

Would he? Really?

What does he really need? Does he need medication, treatment? A warm, dry place to stay? Better government support? Clean clothes?

Let's face it. There is not much, realistically, that you can give him right now, at this red light, in your warm car, on your way to work. I know that. You know that.

What are the bigger issues here?

Does this man really need what you are feeling right now? Pity?

Sorry to distract you. Your light is green.

Where will you go next?

This Ain't Your Mama's Manic Depression- Part 5

2010-11-17T07:12:00.002-05:00

So, in 1949 Australian psychiatrist and part time song writer John F. J. Cade wrote a little ditty called "If Your Mood Goes Up, Baby, You're Goin' Down". It was a smash hit single down under but never made it big north of the equator. It was a unipolar single. Get it? I've got to stop doing those jokes...

No, of course the truth is that would-be songwriter Cade wrote a paper called “Lithium Salts in the Treatment of Psychotic Excitement”, which was published in the Medical Journal of Australia. He was convinced that not only was the BCS way of determining a college football champion every year seriously flawed, but so was our way of looking at manic depression. These patients were not flawed or bad or possessed or any of those things. They must have, thought Cade, a biological disorder that could be treated.

Cade studied potential toxins in the urine of patients with manic-depressive illness, such as urates. He then decided that he would inject lithium urate, then later on lithium carbonate, into guinea pigs for study. He wanted to see what effect these substances would have on activity and behavior in the guinea pigs. Lo and behold, he found that the animals he injected with these substances became lethargic and subdued for several hours. In other words, they were no longer party animals! Cade could sleep a few hours between experiments without loud guinea pig music blaring from the basement downstairs, and everybody was happy. He then injected several highly agitated sufferers of mood disorders with lithium. The effect was dramatic! They became docile, sedated, didn't want to do much, had a harder time thinking clearly and making decisions, and were generally much less agitated. Sort of like, you know, Republicans.

Cade treated ten people with mania, all with pretty good results. Only one of them switched back to the Democratic Party after the treatment. He also tried his new treatment approach on six people with dementia praecox (what we now call schizophrenia, a devastating illness that affects people in the prime of life), and three with chronic depression. These trials lead to less spectacular results. One of the particularly psychotic patients went on to be a charter member of the Tea Party and wanted to pull all funding from mental illness research and treatment facilities. Adjustment of his antipsychotic dose finally resulted in refunding of St. Elizabeth's Hospital in Washington, DC. Whew. In spite of these stellar results for the treatment of acute mania, lithium was not approved for treatment of that condition by the United States FDA for several decades after that. Imagine. The US government not wanting to do something that clearly works. Unheard of!

In part 6, we will move to the 1940s and 1950s, a time when WWII raged on and housewives were told that their husband's shirt collars were not clean and bright enough. During this period, most patients who were loud, excitable, and agitated did not receive a diagnosis of manic depression or bipolar disorder, but were labeled with...

...wait for it...

This Ain't Your Mama's Manic Depression- Part 4

2010-11-12T15:20:00.002-05:00

So, for those of you who came back to talk about condoms and condominiums, I was kidding. Really.

Now, after the turn of the century, a German fellow named August Wasserman was thinking about microbiology. He could not being himself to think about macrobiology because bugs the size of houses made him have nightmares and kick the covers off the bed, leading his wife to banish him to the couch in the living room. Therefore, he started to think about tiny bugs that might lead to human illnesses. Eventually, he came up with a technique that allowed him to detect in spinal fluid the antibodies to the organism that caused syphilis. Finally, we were making progress towards finding a cause of "madness" that could be treated.

In the same year, another German microbiologist named Paul Erlich came up with one of the first effective treatments for syphilis using arsenic compounds. It was crude. It was dangerous. It made the authorities look suspiciously on husbands who began losing their wives to arsenic poisoning. They all claimed that they were just treating their spouses' infections, but... This treatment did indeed decrease the incidence of the disease by up to fifty per cent in some European countries.

More and more diseases that caused syndromes that looked like mental illness were studied. Pellagra, cretinism, and Alzheimer's Disease were just a few of the illnesses whose "madness" could often be completely cured when the primary illness was brought under control. Unfortunately, bipolar disorder had no demonstrable physical cause or cure. There were talking cures, of course, as Freud and others were also working on their theories during this same time. It was also thought that mental illness could stem from reactions to life events in vulnerable people.

Sigmund Freud, Meyer and others theorized that people suffered from "functional illnesses", and that these were illnesses of the mind and not the physical brain itself. In this vein, clients did not suffer from diseases. These concept dominated American psychiatry until at least the 1960's.

Next, we will talk about how an Aussie psychiatrist learned to use salt to lick bipolar disorder symptoms.

Salt lick. Get it?

Whatever.

See you back here for Part 5.

This Ain't Your Mama's Manic Depression-Part 3

2010-11-08T13:27:00.002-05:00

So, these two alienists walk into a bar...

Jules Baillarger (1809-1890) and Jean-Pierre Falret (1794-1870) got the bright idea, independently, that they could link manic excitement and depressive symptoms and morph them into one disease process that then might be treatable and save the planet from sure destruction. Jules (I can call you Jules, right?) talked and wrote about la foile a double forme, in 1854. J-P then, only two weeks later, published in the same journal something about la folie circulaire, something he had been teaching his students about for ten years. Talk about the right hand not knowing what the left hand is doing!

Both of them described periods of alternating melancholia and mania, interrupted by periods of normal mood, sort of like US presidential politics and election cycles. Both claimed to be the originator of this theory. However, little did either of them suspect that a dark horse was rumbling up behind them, ready to snatch the honors from them both.

Emil Kraepelin (1856-1926) wrote his Textbook of Psychiatry in 1899, and in it he described the modern concept of bipolar disorder. He thought that all mood episodes were connected somehow and thus could be treated in concert. His "Manic-depressive synthesis” was a major breakthrough in the classification of mental illnesses. Kraepelin was a very detail oriented man, and his patients were some of the most knowledgeable of the day. He did informed consent before informed consent was cool. Unfortunately, he had little to nothing to offer in the way of treatment, because there really were no good treatment options for mood disorders in his day. Talk about being ahead of your time! The eighth edition of Kraepelin’s Textbook had a chapter on “manic-depressive insanity” that was over two hundred pages long, but the corresponding “Treatment” section was only five pages!

Now, there were some people who started to think that maybe there were some unseen causes of mental illness. No, not going back to the spirits and ghosts of years before, but thinking microscopically. Could there be bugs or germs or other little tiny unseen things that could affect how we felt and acted, even though they were too small to detect with the naked eye?

Well, if your eyes are naked go get some tiny clothes for them and meet me back here for Part 4 of this series when we will do one of the following:

1) Explore how mental illness and syphilis might be connected.

2) Look at the relationship between condoms, condiments, and condominiums.

3) Try to explain why the word "paramecium" is most likely too difficult for George W. Bush to pronounce.

Later!

This Ain't Your Mama's Manic Depression-Part 2

2010-11-07T12:21:00.003-05:00

When I left you last, the priests were kicking some doctor butt as they took over the gig of casting out demons and ridding afflicted citizens of evil Indwelling Caspers that caused them to spit like cats and tear their designer clothes. Casting out demons was hard work, and as the priests exhausted themselves by flinging holy water and brandishing shepherd's crooks, the doctors took the time to sit back, have a snifter of brandy and ponder the whole mess. What happened next?

The doctors became Renaissance Men. They learned how to keep little notebooks full of drawings of spreadeagled men and flying contraptions and mathematical formulas for the making of New Coke. They became enlightened. They walked about saying, "I have an idea! I have an idea!" and little light bulbs came on above their heads. It was quite like a Stephen King novel. They decided to call this whole period in history The Renaissance and Enlightenment after themselves, because as you know, doctors are a narcissistic breed.

It was during this period of time that the doctors started to think about these strange goings on and even stranger people, heretofore called witches and the demonically possessed and New Dealers, and they began to wonder if they were not, after all, sick. Like, with illnesses. That maybe could be treated. They began to think that melancholia and mania were two separate processes that could be attacked from different angles. They were on the right track with this thinking thing, trying to figure out what was going on instead of throwing water at it and hoping it ran down the hillside into a herd of swine and swept itself into the sea and a mass suicide. The priests? They went back into the sacristy and began to polish silver and clean doilies, knowing in their hearts that reimbursement for the treatment of mental illness could never keep pace with the selling of indulgences and that they would come out on top in the end. The two groups, doctors and priests, never met in regular season conference play again.

Now, on with our story. It took the English Physician Robert James (1705-1776) to connect the two syndromes of melancholia and mania. He saw in this "an absolute necessity for reducing Melancholy and Madness to one species of disorder", thinking that this would give him the upper hand in controlling the whole shooting match. He was so close. He thought that congestion of blood in the brain was causing the maladies. He did see, however, that these patients (they were back to being patients now, no priests to be seen anywhere) had an illness that was prone to change, that is "Melancholic patients easily fall into madness". Now we were getting somewhere.

When we meet again, I will tell you the story of two French alienists. These two men, Jules Baillarger (1809-1890) and Jean-Pierre Falret (1794-1870) agonized over making the trip to Roswell, New Mexico, to put on little tin foil hats and wait for the little green men to arrive or go back into their labs and work on the cyclic nature of what we would later call bipolar disorder. Fortunately for us, they were smart enough to know that alienist is from the French word "aliene", which means insane. They were not insane. We are that much better off today.

Look for Part 3 soon, after this word from our sponsor, Reynolds Wrap. Bigger rolls, stronger sheets, more radio wave-shielding coverage than the bargain foil. Reynolds Wrap. Find it in your grocer's paranormal section.

This Ain't Your Mama's Manic Depression-Part 1

2010-11-06T12:39:00.002-04:00

Mood swings. Manic depressive illness. Schizophrenia-manic depression. Bipolar disorder.

I've heard it called all sorts of things by all sorts of people. Nowadays, we usually call it Bipolar I Disorder, Bipolar II Disorder, or Bipolar Disorder NOS. NOS is shorthand for "I don't have any idea what this really is, but I'll park it in this class of ailments until I get more information and can make my best educated guess." There are many other classifications of mood disorders, and these bipolar ones come in several flavors as well. My purpose with this series is not to get you up to speed with the Diagnostic and Statistical Manual that we use to make diagnoses in psychiatry and mental health, but to give you what I hope will be a fun and fascinating look at where this illness came from, what we think about it today, and where it may be headed. We'll touch on who has it, who doesn't, who thinks they want to have it and why they shouldn't. As always, I welcome your comments along the way. If something piques your curiosity and you want to know more or have me explore something in more detail, I will certainly do my best.

So, where did it all begin?

Once upon a time, there were ancient people living in places like Greece that noticed that their relatives maxed out their charge cards, stayed up all night playing online poker, and took cross country trips without kissing anybody goodbye before they left. Naturally, they were concerned about these behaviors. Being ancient Greeks and pretty damn smart people, they began to reason together about what this change in behaviors might mean. They decided, being pretty in tune with the earth and all things natural, that maladies of mind and body came from imbalances in four vital bodily fluids called humours. There used to be five of them, but the Good Humor (sp) turned into an ice cream venture and got out of the mental health business. Depression was thought to come from an excess of black bile (the word melancholia is derived from the Greek word for black bile). Mania came from having too much yellow bile. A combination of yellow and black gave you the Georgia Tech Yellow Jackets football team, but I hear the ancient Greeks were more partial to the Michigan State Spartans.

Now, as time went on towards Medieval Times and we got a lot smarter (yeah, right), we began to think that mental illness and mood swings in particular were related to witchcraft or demonic possession. As business cycles go, this was not a good time to be a doctor, because priests became the go-to guys for demonic exorcisms and were the guests of honor at neighborhood witch burnings and the like. Doctors had to take second jobs to keep up their dues at the local jousting clubs. It was a dark time for the medical profession. Priests "cured" people, but if they couldn't fix you they could pray for your eternal soul. How could doctors compete with that, I mean really? Basically, if you were mentally ill and had mood swings you were evil. You didn't need treatment as much as you needed a religious rite. Of course, now we have the Religious Right, and those of us who have extremes in mood and behavior are called ultraconservatives. That's another story for another day.

Now, do you think the doctors took all this lying down? Of course not! (Only the ones who were so depressed that they got into psychoanalysis took it lying down, on a couch).

Look for Part 2 soon, and I'll tell you how the doctors battled back in the bottom of the ninth to even the series with the priests, extending the contest and selling even more television commercials.

Caregivers, Mental Illness, Burnout, and Depression

2010-11-03T06:18:00.003-04:00

Your mother has been up all night. She has Alzheimer's Disease and now it has progressed to that inevitable stage of the dementing process where she is paranoid, agitated, and confused. She fidgets and paces and walks all day. She gets out of bed multiple times each night. She has gone out the door into the back yard and tried to escape to the street, wearing only her night clothes. Sometimes she doesn't even know who you are, but you are solely responsible for her ongoing care. You are losing weight, not sleeping well yourself, not able to concentrate, have no interest in your hobbies, and are thinking that it would be easier if both you and your mother died and this was all over.

Your son used to be a strapping, handsome lad with tousled brown hair, deep brown eyes and a quick, winning smile. At nineteen, he won a scholarship, was making good grades his first year in college, and had many friends. Now, he is back home with you. He quit studying, thought his professors were all out to see him fail, and alienated all his friends. He sleeps all day and plays video games all night. His face is sallow, his clothes hang on him, and he drinks too much. He tells you that the end of the world is coming soon. The voices in his head have told him so.

Your spouse is getting worse. The daily six pack of beer has turned into a case. You suspect he is buying marijuana or maybe even cocaine downtown, something he has never done before. His mood is erratic, swinging from angry and mean to insanely happy about everything. He has started fifteen different grandiose projects that will change the world, but can't manage to take out the trash. He hasn't hit you yet, but the arguments are more heated and they come much more often than they used to. You knew about his illness when you married him, but this is much worse than you bargained for. You're frightened, and you wonder if you need to cut your losses and get out. You've made a call to a local shelter for battered women, and you've hidden a packed suitcase in the closet. If it happens again...

Do any of these scenarios ring a bell? Are you or someone you know a survivor, a caregiver, a person who lives with someone who suffers from some kind of mental illness every day? If so, you may be at risk. Your own mental health, physical health, and well being may be in jeopardy. If you are depressed, feeling suicidal, not sleeping or eating, missing days at work, or just feeling like you're close to giving up, what can you do? There is help.

Your own family doctor can be a great asset. See him or her and ask for help in finding resources, local meetings or support groups, or even for help in treating your own depression or anxiety that commonly comes from the stress of being a caregiver.

Clergy can also be helpful. If your spiritual tank has run dry, speak with a trusted priest or pastor or minister who can listen to your concerns and guide you in the right direction.

Counselors, therapists, psychologists and psychiatrists may also be able to help if the stress of caring for someone you love has lead to your own mental health issues. This is not uncommon, and it is certainly nothing to be ashamed of. Seek help for yourself so that you may continue to provide the support for your loved one. You can't help someone else if you're hurting and broken yourself.

Caregiving and living with those who have dementing illnesses, mental health problems and substance abuse or dependence are hard work. Sometimes love and good intentions are not enough. Sometimes you need help yourself.

If you need it, get it.

Today, please.

Psychiatry A to Z: Orientation

2010-11-02T19:57:00.002-04:00

I had to write this one.

You, my dear and constant readers, understand that, right? You know me by now. You know a little more about where I stand on treatment issues, and you know that when Psychiatry A to Z: O came up, this post had to be written. Some of you will agree with me and some of you won't. I already anticipate and welcome your comments and will respond to them all. I promise you that.

O, my friends, stands for orientation in this case. Sexual orientation. If this is not a hotbed of dissension (pun entirely intentional) then I don't know what is. There have been beatings, bullying, slurs, demonstrations, shaming, and all manner of denigration of those with alternative lifestyles and outright expressions of their gay orientation. Don't ask, don't tell. As far as I'm concerned, this might as well be don't understand, don't care.

In my home town, there was recently a rally that saw representation from the KKK, the gay community, the sons of Confederate Veterans, and the group Proud Ally out of New York. At issue was whether a student should be required to see gay clients with or without remedial education, or whether this student could decide not to see these folks if she could not work to help them see the light and change their orientation.

Maybe I was just well trained in my psychiatric residency program (I happen to think I was). Maybe I was raised right. Maybe I've learned a thing or two in my journey through the last thirty years of school, training and seeing patients of all stripes. Maybe it's all of the above. Whatever the case may be, here are some of my own views on this issue of orientation.

1) We are all people, and we all have stories. As a psychiatrist, I am trained to listen to you, understand what you bring to the table and try my best to help you. That means meeting you wherever you are. If I am so concerned about, afraid of, or preoccupied with your sexual orientation that I lose sight of your depression, psychosis, or drug and alcohol abuse, then I cannot help you.

2) I should try to help anyone who comes to me for mental health services who I feel that I am qualified to help. If the fact that you are black or female or gay or unemployed or rich or poor gets in the way of my doing that, I should seriously consider going into a different line of work.

3) Gay people get depressed. They have relationship problems. They lose their jobs and have financial problems. They may be suicidal. They should not be discriminated against and denied excellent treatment any more than I should because my eye color is green.

4) Hiding because you are gay does not foster good mental health. Hiding who you are, what you feel, or how you want to live is not conducive to creativity, generativity, or being a productive member of society.

5) Those who put all gay citizens in the same box and then tape that box tightly shut miss out on knowing some great people. I have known gay teachers, doctors, lawyers, musicians, and ministers. They have all been engaging, bright, intelligent, creative people who just wanted to be given the same opportunity to live their lives that all of us have been given.

O, then is for orientation.

I welcome your views on this subject.

Compliance versus Adherence

2010-11-01T16:56:00.004-04:00

compliance |kəmˈplīəns| (also compliancy |-ˈplīənsē|)
noun
1 the action or fact of complying with a wish or command : they must secure each other's cooperation or compliance.
• ( compliance with) the state or fact of according with or meeting rules or standards : all imports of timber are in compliance with regulations.

Back in the days of Marcus Welby, MD, (yes, I remember him, and boy does that date me now), it was a kinder, gentler time. Bright young lads (yes, again, most of them were lads, not lassies) went to medical school, learned a set of hard and fast rules about eliciting symptoms, detecting signs and physical findings on exam, making a solid diagnosis, prescribing a treatment based on the best evidence known at the time, and then communicating said treatment to the patient. The doctor was a master of his craft. He knew his stuff. He cared about you, but he was, in the best Marcus Welby tradition, a father figure who would always tell you what was best for you and then expected you to follow his advice to the letter. As long as you did that, got your tests done, took your medicine, and came back for your scheduled follow up appointment, all was well in the healthcare universe and you got better.

You were a compliant patient. You complied with the doctor's standards of practice and the healing arts. You rarely if ever asked questions. This was way before Google, remember. The doctors bookcases full of musty old textbooks were the authority, and you weren't about to get anywhere near those suckers to scribble your own differential diagnosis and present it to your doctor.

Fast forward to the present day. We are not so much kind and gentle today as we are politically correct. We cannot tell those healthy souls who had rather be on disability than work for an honest day's wage that they are full of it. We must not bruise their gentle psyches. We must give them wastebasket diagnoses in order to code and bill, but the diagnoses often move us no further down the road to long-lasting health, just to more documentation to maintain the sad status quo. If the patient comes up with her own diagnosis, based on a recent episode of Oprah or an internet questionnaire, then that's all the better. The patient is truly in charge of her own healthcare. All we have to do is nod and smile and tell her how wonderful it is that she was able to self-diagnose with such aplomb. We come up with softball treatment plans and easy to swallow directions for people who don't want to work to lower their weight or their cholesterol or blood pressure. Pills, please. Tests, please. There must be something wrong with me. You, dear doctor of mine, just haven't found it yet.

Please.

Stop the merry-go-round. I want to get off.

We do not need to go all the way back to Marcus Welby or Ben Casey or even the good Dr. Huxtable. The fix is simple.

I want to be your doctor, and I want to give you the benefit of all those years and all those dollars I spent becoming a physician. I want to listen and diagnose and prescribe and treat and watch you get well. That's fun for me! It really is! I do not want to shove things down your throat (except maybe the occasional tongue depressor) and tell you to take it or leave it. I know, I really do know, that you are fully capable of finding some really good information on the internet and elsewhere that I did not give you myself. Excellent! Share it with me. Tell me about it. Let me learn from you. (I have not stopped learning since the day I left my residency) Teach me. It will not only help you, but it will help the next hundred or the next thousand patients who come after you.

There is one caveat here.

When I have finished telling you what I think and you have finished showing me the papers you found on WebMD, we need to come to a good solid consensus and agreement as to 1) What it is that ails you, if anything, and 2) What we're going to do, together, to get it fixed or treated appropriately. I do not expect you to comply just because I tell you to.

I do, however, expect you to adhere to the treatment plan we come up with. BIG difference.

Comply = I own it, you do it or else, I'm responsible for it. I'm your superior in every way.

Adhere = We own it, we do it, we're responsible for it. Together. We're a team.

Compliance or adherence. Which had you rather strive for? Which side of this fence has your medical care most often been on?

adherent |adˈhi(ə)rənt; -ˈher-|
noun
someone who supports a particular party, person, or set of ideas : he was a strong adherent of monetarism.

Psychiatry A to Z: Narcissism

2010-10-10T00:03:00.004-04:00

Well, I see that you have come back for more of the best blog with the most absolutely stunning content on the planet. Good for you! It really shows what good taste you have that you would come back here, time after time, to learn from the master. After all, you know quality when you see it, yes?

Yes, If I must say so myself, and I most assuredly must, I am one of the finest bloggers around. I am so important that Gruber asks me about Mac news and Tech Crunch is always looking for my views on new hardware and usage trends. Why, even the American Psychiatric Association knows that as my opinions on mental illness go, so go the opinions of their other thirty thousand plus members. I of course take this superiority for what it is, a level of achievement and stunning insight that few have, even fewer to the extent that I possess.

I am so glad that you came back. You are the reason I do this, to make my blog look better than all the rest when you flock to my posts and clamor for more before the next one is even written. My fans. My groupies. Although I would be just as stunning without you, it makes my brilliance all the more bright when it is reflected from your adoring eyes.

I see this blog as the first in a long line of written, spoken, and video productions that will take the world by storm. The sky is the limit. I will be picked up internationally. Once they see me they must have me, and money will be no object. People will pay any price to possess something that they see as perfection itself. This medium is ideal for one so talented as me. It begs to be used, to be propagated around the world into every corner of cyberspace.

Am I special? Well of course I am! Silly of you to even have to ask that question. So special that some of my posts may only be intellectually accessible to the brightest minds, leaving the rest of you scratching your heads and wondering at the shrouded brilliance that lies just beyond the grasp of your eager but feeble minds. Come ahead, try, partake, as the lot of you only add to my cachet. I don't need you, not really, but the praise is intoxicating I must say. It grows on one, that's for certain. I would never give it up, no never in a million years. I deserve all of it and more. I deserve it and I shall have it, because I am indeed as special as I seem to you.

Yes, I deserve every accolade that has come my way, and I will relish in those to come. There will be many, many more. Others will marvel at my successes and my ability to parlay one fortuitous turn into multiple branches.

Well, I must close now. I am so glad that you saw fit to come back to this series on Psychiatry A to Z, probably one of the best of its kind ever written. I hope you learned something about narcissism, as I am most certainly the only person who could have done this good a job in explaining it to you.

See you next time for the fifteenth installment in the series.

Psychiatry A to Z: Mania Mini Myths

2010-09-28T11:05:00.008-04:00

Myth #1

"When I'm manic, I can get so much done!"

As a resident, I once treated a medical school faculty member who was manic. "My boss told me to tell you that we don't want to get rid of my manic symptoms completely. I get so much more research done and can write more papers when I feel like this. Can we just keep the depression away?" Unfortunately, it is quite difficult to pick and choose which aspect of the disease that we treat. Mania, while seemingly a great engine for productivity, more often than not leads to sense of overwhelming energy that causes the wheels to spin madly but keeps the vehicle from moving forward.

Myth #2

"When I'm manic, I'm the life of the party!"

Well, maybe, if your idea of a good time is dancing on your boss's piano with a large lamp shade on your head while guzzling tequila from the bottle. Sometimes the euphoria of a manic episode leads to merriment that turns to embarrassment when the cops arrive at the door. The rapid speech, punning, off color jokes and impulsive behaviors can lead to a quick ushered exit from the party that you thought you owned.

Myth #3

"When I'm manic, I just need to drink a little or take some pills to slow me down."

Abuse of alcohol and other drugs is very common in folks who suffer from bipolar disorder, and are often the behaviors that lead to trouble with finances, job status, relationships and the law. Those two or three beers to help with sleep at night turn into a case or two on the weekend and that leads to missed work on Monday morning and loss of a job and ....well, you get the idea.

Myth #4

"When I feel this good, I don't need treatment!"

Mania is seductive, especially the first time it happens and your poor brain does not know what is happening to it. After all, who wouldn't want to feel sharp, witty, sexy, energetic and able to run with the big boys on two hours of sleep per night? The problems is, once the all too short feeling of mania subsides. a severe depression can be lurking right outside the door, with its dark moods, lack of energy and suicidal ideation. Ongoing treatment to balance mood, energy and productivity is key.

Myth #5

"When I'm manic, I'm so much smarter and more creative than everyone else!"

You may be a legend in your own mind, but those racing thoughts, ideas for new inventions, and plans to write the Great American Novel are often here one minute and gone the next. The people that you scoffed at and made fun of when you were manic may not be anywhere in sight when you start to slide down the slippery slope of depression.

Mania is often misunderstood. if you or someone you know struggles with bipolar disorder, get help from someone you trust.

Psychiatry A to Z: Laughter

2010-08-28T06:54:00.002-04:00

"Laughter is the best medicine."

I believe that the origin of this quote is not the Reader's Digest, as many of you might remember, but may go back to the Romans or the Bible or at least some ancient person somewhere back there who needed something witty to say at a mashed potato circuit fundraiser one Thursday night and couldn't come up with anything better.

As Farmer Hoggett said in the 1995 movie Babe, "That'll do, pig. That'll do."

Laughter is multifaceted. It can be light, airy, lilting and fun. It can set your soul to singing. It can lift you up from the darkest depression and can stop a foul mood on a dime, spin it around and make it march off the other way. When laughter confronts anger, the latter has no choice but to break into a grin.

We laugh for many reasons. The Gestapo guard laughed as he rifle-butted an unsuspecting Jew in the back of the head, knocking him to the ground. Vincent Price laughed maniacally at the end of Michael Jackson's Thriller. Heath Ledger may have gotten into the twisted laughter of the Joker a little too much. Glinda the Good Witch twittered as she told her evil counterpart "You have no power here". Babies laugh and giggle and we have no choice but to smile and giggle back. Remember the recent Internet clip of the giggling baby? Just try to watch that with a straight face. You can't!

Laughter can be a powerful force for good. We try to cheer people up when they are down. We tell jokes. We tickle them. We show them funny pictures. We rent a comedy. We endure anything Jim Carrey. Laughter stimulates feel good hormones. It loosens up the facial muscles. It relaxes us.

In mental health, laughter can also be a signpost to other things. I saw a lady in an emergency department recently who was just a hair shy of being fully manic. She sat still in front of the telepsychiatry camera, trying valiantly to put on her best front for me, hoping that I would recommend her release, most likely knowing that I would not. She would answer a question with as straight a face as she could muster, but the tell-tale laughter that bubbled up around her clipped controlled answers tipped me off. She was about ready to blow. She knew it, and I knew it. She had been there before, and so had I.

Laughter can be the thin veneer that covers the darkness below. I have seen those with the absolute darkest secrets tell the most wonderful jokes. It can patch a hole in the soul that is big enough to drive a Mack truck through. It can come out disguised as sarcasm, biting and cold and harshly puckish, taunting and challenging. Sometimes, the delicate sutures of laughter are all that keep a gaping wound closed so that it can heal from the inside. Sometimes, that laughter, a body's own natural defensive medicine, is better than any pill I could prescribe or any intervention or interpretation I could offer.

Make it a point to seek out laughter today. All in all, it is your friend. Most of the time, it comes dressed in its own clothes and behaves itself. The lilting tones, the lightness, the joy are all real. They can be the water wings that keep you from drowning when you thought you had gone under for the last time.

Do you remember a time when laughter helped you through something?

Psychiatry A to Z: Kevorkianesque

2010-08-21T08:54:00.007-04:00

It was sometime shortly after the second coronation of Ronald Reagan.

He was a young fellow. I was a slightly older fellow, but not by much. He was a new resident. I was just far enough ahead of him in the process to know how much I really didn't know yet. He was presenting a case to me this morning, and I was supposed to give him guidance on how to proceed. To say that this was the blind leading the blind would have been a little harsh, but let's just say that one of us was wearing dark glasses and the other was skilled with a cane.

"This is a forty-five year old white female who presents with depression that started two months ago," he began, keeping to the script. Little did I know how far off of it he would veer in just a few short minutes. I drank my coffee oblivious to the cataclysmic pronouncement that would issue from my protege in a few short minutes. He continued his presentation. Mundane. Expected. Routine. Sleep, appetite, energy, concentration, depressed mood.

"She told me that she had been thinking of killing herself," he stated matter of factly. "She said that because of her chronic pain and her inability to take care of her children and herself that she was ready to end it all."

This young-middle-aged lady had terminal cancer. She had been sent to us at the Department of Psychiatry and Health Behavior by her oncologists to complete a mental health evaluation and to provide suggestions for care that would complement their palliative measures already in place. One could surmise, being trained the way were in the 1980s, that this would mean supporting her in her struggles to combat this terrible disease and to exit life as gracefully as possible given the hand she had been dealt.This would include treating any anxiety and depression we found, doing psychotherapy as indicated and prescribing medications if warranted. All with the idea that we would help her live as long as possible.

"Did she have a plan?" I asked.

"Yes, she was going to stockpile her pain pills until she had enough to kill herself. She had already been reading about how to do it." (Remember, dear readers, that this was several year before one could easily hop on the Internet and search for anything, much less easily find do it yourself prescriptions for suicide)

"What did you tell her?" I asked, sipping my coffee and expecting the stock answers that a resident at this level of training would regurgitate.

"I told her that I thought that was a good idea." He looked at me steadily. He never blinked.

"Hmm." My brain screamed, but even at that tender stage of supervisory expertise and experience my training kicked in like a generator after a lightning storm. I looked steadily back at him. "Tell me about that. What were you thinking when you said that to her?"

"In my culture, if someone is faced with this set of circumstances and they have come up with suicide as the best way to die with dignity and save face, then we feel that this is the best course to follow," he said steadily and with obvious conviction.

You see, my protege had been raised in an Asian culture, light years and thousands of miles distant from my own upbringing in the genteel, protective, paternalistic southern United States. Here we knew better. Patients were ill and needed our guidance and direction. Or so the training went in those days.

"I see," I said evenly.

The rest of the supervisory session was interesting to say the least. Like any good senior resident, I took this issue to my own supervisor at our next meeting and discussed it at the next level.

What do you think about letting patients who know they are facing death, imminently or maybe not so soon, decide to take their own lives? Should they be allowed to do this on their own? Should physicians help them? Should we advise against it, or should we step out of the way?

I welcome your thoughts and discussion.

Chronic Is Not a Four Letter Word.

2010-08-17T21:21:00.002-04:00

Chronic.

Longstanding. Long lasting. Hanging around. Not going away any time soon. Sticking with me. Keeping me sick. Pissing me off. Messing with my head. Keeping me down.

Chronic illness is here to stay people. I'm sorry if this terminology worries you or upsets you or makes you angry or provokes wrathful comments to my blog (well, OK, I like provocative comments on my blog, so that's OK). I deal every day with folks just like me and just like you who have chronic illnesses. Chronic depression. Chronic schizophrenia. Chronic alcoholism and other drug addiction. Chronic personality disorders.

I love my patients. I would never in a million years call them "chronics" because I think that is a stigmatized use of the word. However, I always have and always will tell them if I believe that they have a chronic illness, that is, one that will most likely be with them the rest of their lives in some way, shape, or form. I sincerely wish that I had the absolute cure for the terrible disease that we call schizophrenia. If I had it, I would give it away. Free. To anyone who wanted or needed it. I would stomp on the neck of that disease and keep it on the ground until the last breath was gone from its nasty, life-sucking body. I would burn its carcass and dump it in the sea. But I digress.

Chronic illness means that you likely need to keep coming back, to borrow a phrase from AA, so that you may function as well as you can in SPITE of an affliction, instead of feeling sorry for yourself BECAUSE you have an illness. I don't deal in making excuses for people. I deal in trying to help them better themselves and rise above any limitations that their illness may saddle them with.

One pet peeve of mine during the twenty years I worked in a busy mental health center was that we started to implement a "three strikes and you're out" policy. In our clinics, if you missed three appointments in a row for ANY reason (I think that later it actually was changed to two) your chart was closed. As if this was going to make you go away? As if this was going to magically cure your psychosis and make your voices stop bothering you? As if this meant that you would never darken the door of the center again? Hardly! People with chronic mental illnesses have problems coping with life. Hello! They cannot hold jobs. Their marriages fail. Their transmissions fall out of their cars and they cannot afford to get them fixed. These things might just make them miss a few appointments, but they do NOT make their mental illnesses go away. If we simply close their charts, lessening the numerical burden on counselors and doctors in the outpatient centers, guess what happens? These poor folks who really need good care will gravitate to the emergency departments and jails and crack houses. They will rarely get what they need, and they will never get what they deserve--the same good health care that my family and I get.

Chronic does not mean throwaway. It does not mean out of sight, out of mind. It does not mean "if we don't see them, we don't need to worry about them".

What it means is a life long commitment to early and proper diagnosis, assessment of psychosocial needs, and excellent treatment that affords the souls afflicted with these debilitating illnesses the same shot at a good life that I have. In a country like mine, should anything else be considered enough?

What do you think?

Psychiatry A to Z: Jail

2010-08-16T10:34:00.001-04:00

I followed the guard down the clean, bright hallway. Every footstep echoed loudly off the institutional green walls. There were no pictures, no windows, no ornamentation of any kind. This was a place devoid of hope.The floors gleamed from the nightly polishing they received from the trusty manning the machines. The brightness of the floors, the walls, and the overhead lights existed in stark contrast to the dark mood of the place. County jails were not known for their carnival atmosphere.

We reached the thick metal door of the pod. Odd name for the different groups of cells around the jail, I thought, but then not. These were pods that, like large spacecraft, contained ostracized astronauts who drifted in that silent void that was pretrial limbo, cut off from the rest of society as surely as if they had been launched there on purpose. Which of course, they had been. Out of atmosphere, out of mind. The guard found the right key from the dozens that jangled and clanked on the large ring attached to his utility belt, inserted it in the lock, turned it with a grinding of metal on metal, and tugged hard on the door. We entered a world so foreign to me that it almost took my breath away.

I stepped into the bowels of the maximum security section of the county jail, a gray place with slits for windows high up on the concrete walls to let in just enough light to make one remember what it had been like to see the sunshine in the other world. The pod was a large expanse of nothing. A table or two bolted to the floor, a railing here and there. No color. No stimulation. No air. Stifling in its nihilism.

“He’s over here.”

We turned to our right and entered a smaller section of the pod, behind another door and another lock. Two more guards. Two tiers of small cells behind yet other heavy metal doors. Bolted tables in the open area, open showers around the periphery. Inmates in here stayed in these hard, cold cells twenty-three hours out of every twenty-four hour day. We trudged up the stairs, metal footfalls echoing. Everything in here echoed. It was not enough to feel trapped and depressed and angry one time. You had to hear it come back to you off these walls and floors and metal doors over and over and over again. Up the stairs to the row of cells accessible only by a catwalk.

“Hey, Doc, c’mere! Doc, c’mere man!”

Ghostly faces peering through thick, dirty glass windows. The Doctor was here. This was the one chance they had to get the Doctor’s attention. Just the fact that I was wearing street clothes and that my hair was cut marked me unmistakably from afar. I was not here to see them. I ignored them in spite of the urge to respond with some word of hope.

“Here he is, Doc.”

The guard gestured to the third cell from the top of the open metal staircase. My patient’s home. The metal door had no curb appeal. No flowers on this stoop. No pretty door knocker. No welcoming sign that told me his name. Just a dingy glass window and a slot big enough to shove a slop tray through.
I peered though the window and there he was, curled up in a fetal position on the cold floor, completely naked, hugging the wall, his boney back to me. He was thin, gaunt, dark-skinned, and looked like he hadn’t bathed in a month. His hair was matted. He had a several weeks’ growth of beard.

“Albert?” I called out tentatively. “Can you get up and talk to me? It’s Dr. Smith, Albert.”

No response. He lay there as if dead. For a second I wondered if he was and if so, who would care.

“Albert!” A little louder.

He leapt up with the grace of a gazelle and was at the door, his grizzled face inches from my freshly shaved one in two seconds. I was not a greenhorn, but this startled me just the same.

“Here’s Johnny!” he cackled, doing a pretty darn good impression of Jack in The Shining. Ok, points for his knowledge of movies and good use of one-liners.

“Albert, I need to talk to you about…” I began.

“WHAT THE FUCK DO YOU WANT?” he bellowed, spittle flying into the glass that tenuously kept his reality two inches from mine. He began to pound the glass with his fists, pounding and pounding and laughing now, a full set of yellowed but straight teeth grinning at me. I felt oddly disconnected, like I was watching something out of the Exorcist. Linda Blair visits an old-time Biblical leper colony on the outskirts of town beyond the wall.

“Albert, can you tell me why you’re here?” I tried again, knowing already that this whole exercise was useless.

“He was using meth before he got here,” volunteered the guard behind me. His large khaki presence did little to make me feel secure.

“Do you drink, Doc?” Albert asked me, still grinning that hideous psychotic grin that held no joy. “Do you smoke, do you toke, do you drink, do you stink?” He had backed away from the door now, standing naked in the middle of the cell, arms and hands moving in some strange bellicose ballet.

I tried for a few more minutes, but it was useless. His psychosis was too severe.

“We’ll get him to the hospital.”

In this place where confidentiality was a cruel joke and humane treatment was a paper exercise, I backed away, descended the metal stairway, and followed the guard out of the pod and back to the front of the jailhouse. I signed myself out, gathered my belongings, and walked out the clean glass front doors into the bright sunshine of a beautiful southern spring day.

The crisp, bright American flag fluttered in the breeze above my head as I walked down the sidewalk to my car.

My country, ‘tis of thee, sweet land of liberty, of Thee I sing.
Land where my fathers died. Land of the pilgrims’ pride.
From every mountain side, let freedom ring.

Just not for Albert.

Not today.

Signs and Symptoms and Diseases, Oh My!

2010-08-15T08:41:00.004-04:00

Subtle differences abound in medicine, mental health treatment and life.

I often get asked questions about signs versus symptoms versus disease. Aren't they all the same anyway?

If you go to your doctor and you have a pronounced droop of the muscles on one side of your face, you are not swinging your arm normally on one side when you walk, and you are not able to talk normally, these are signs that you may have had a stroke or other neurological problem. Some strokes even cause indifference so that you notice very little change in how you feel, but others can easily see that something is wrong. If you are clutching your hands to your chest, you're turning blue around your mouth, you're sweating profusely, and your skin is pale and ashen, these are signs that you may be having a heart attack. You need medical assistance immediately.

If you tell your doctor that you suddenly feel so weak on one side that you cannot comb your hair or walk without assistance, you are reporting symptoms. If you are able to tell your doctor that you have such chest pain that it feels like an elephant is sitting on your chest, this is a cardinal symptom of a cardiac event.

What might lead to these signs and symptoms is neurological or cardiovascular disease. These diseases may be silent. They are the underlying processes that undermine the health of arteries, cause the heart to work harder than it should, and may lead to overt illness if not prevented, diagnosed, or treated.

Ideally, of course, we would all like to prevent mental and physical diseases so that we never develop signs and symptoms or disease. That is optimal and is a wonderful goal to have. If that is not the case, however, and you develop signs and symptoms, please get to the emergency department, your doctor's office, or an urgent care center or clinic as soon as you can to have someone check you out and provide the care that you need.

Your life may depend on it!

Psychiatry A to Z: Insomnia

2010-08-14T22:45:00.003-04:00

It happened to me one night out of the blue.
To this day I still don't know why.
I could NOT get to sleep.

I finally decided, after tossing and turning for an hour or two, that I would get up and do something in the hope that I would eventually get tired and head back to the land of Winkin', Blinkin', and Nod.

I went into the living room and turned on the television. Now, if you know me at all you know that I am NOT a television watcher, so this was the first big red flag saying that something was really wrong. I flipped through the channels, finding that even the most boring of infomercials just proved stimulating to my already overwrought brain and that my eyelids if anything jacked themselves closer to the ceiling. No dice.

I picked up a boring book, reading a page or two until my brain screamed silently, "No, you idiot, I don't WANT to read. You can't trick me! I want to sleep. Try again!"

After a few more of these fruitless maneuvers, I went for (for me) the big guns.

I am not a big drinker at all, but I knew there was an open, half-empty bottle of wine in the dining room that we had started on at dinner one night. I thought that if I drank a glass or two or three that surely I would be sleepy enough that I would slide on out (or pass out if it came to that). I got a glass, found the bottle and poured glass number one. Somewhere in there I think maybe I took a Benadryl or three as well.

Now, everybody has nights that they just don't sleep very well, I know. This was different. The longer I stayed up, going on an hour, then two, then more, I got scared. I became just a little irrational. I began to have crazy thoughts that I would NEVER sleep not just that night but EVER. I was with it enough to know that this made absolutely no sense, but I still got a little scared that I was out of control and that my body was doing its own thing.

"Sleep, damn you. Eyes, close! Brain, shut down!"

"We're sorry, Dave, but we can't do that."

Well, eventually I did go to sleep, I didn't die, and I've never (thank God) had another night quite like that one.

A few pearls about sleep and insomnia (freely giving you the disclaimer that this is one time that I do NOT always practice what I preach):

1) Everyone has different sleep requirements. Some folks do very well on five or six hours of sleep (are you looking at me?), while others require eight to twelve hours to function at their best. Try to sleep as much as your body needs to function at your best. A simple way to gauge this is to go to bed at a reasonable hour and get up when you wake up, without setting an alarm clock. Try this some time when you are not harried with work obligations, etc., and see what your body's natural alarm clock tells you about when to rise and shine.

2) We require less sleep overall as we age. If an older person goes to bed at eight or nine o'clock and is upset because they wake up at three AM every morning, they may need to go to bed much later to sleep through to "morning".

3) Simple, regular patterns are the best. By this I mean going to bed at the same time every night and getting up at about the same time every morning. Getting up at 4 AM on weekdays to get a head start on the work day and then sleeping until past noon on the weekend to "catch up" does not work. Your sleep deficit cannot be made up that way.

4) Practice good sleep hygiene. Have a routine towards bedtime that varies little day to day. No exercise late in the afternoon or evening, no caffeine, no heavy meals late in the evening. When you are ready for bed, turn out the lights (or at least turn them way down), turn off radios, televisions, iPods and other distractions, and lie down with intention of going to sleep. If you want to read before bedtime, sit up in a chair or on the couch. When you're sleepy, go to bed.

5) Watch medication or other substance use. While some medications are obviously prescribed as sleeping pills, some of them are better than others. Some short acting sleepers like Restoril or other benzodiazepines may work to get you to sleep, but may not keep you there. Their short half lives make for less hangover the next day. Most of these types of sleeping pills are also targeted for 1-2 weeks of continuous use. If you need something to help you sleep after that period of time, talk to your doctor about what's going on and why, and what the possible solutions are. Some antidepressants (Elavil, Trazodone and others) may help with sleep because their primary side effect is sedation, but they may cause daytime drowsiness or hangover effects the next day. Drinking alcohol, while initially soporific, usually backfires later. The wine I drank on my fateful night just made me more nervous and jumpy and didn't help my insomnia at all.

6) Finally, remember that insomnia may be a primary disorder on its own, but that it is just as likely a symptom of other problems that may be medical or psychiatric or both. Medical illnesses like congestive heart failure, sleep apnea and restless leg syndrome may cause sleepless nights. Chronic substance abuse (amphetamine, cocaine or other stimulant abuse, or even ongoing abuse of sedative hypnotics) can cause severe rebound insomnia. Anxiety and depression have insomnia as a primary symptom in many cases. With anxiety, folks often have trouble getting to sleep initially, and with depression the classic problem is early morning awakening (2-4 AM) with difficulty getting back to sleep.

Have you had nights like mine where you could not get to sleep?
Have you experienced chronic insomnia?
Have you found things that helped you get a good night's sleep?
Please feel free to share!

Psychiatry A to Z: Hallucinations

2010-08-10T21:04:00.002-04:00

"There! Did you see that? Did you see 'em, Doc?"

He sat across the table from my associate and me. We were doing mental health examinations for the probate court, and our charge was to decide whether or not he needed involuntary commitment to a psychiatric hospital for treatment. He was dressed in a bright orange standard issue jumpsuit, clinking silvery metal handcuffs, and lightweight leg irons. He had a three day growth of beard, three missing teeth in front, and long greasy hair that had forgotten the last comb it had gone out with. All he was missing was a handbag and matching shoes. I guess they had frowned on accessories at the local county jail.

"Look, look, there they go, walking right down the side of the table. Do you see 'em, Doc?" he asked me but looked intently at my associate, a psychologist with many years of mental health experience under his belt. We turned towards each other, raised one eyebrow each as if on cue, and turned back to the patient. We had been doing these exams together for over ten years. Joking repartee, intense interrogation, good cop-bad cop-we had a repertoire that was legendary. I took this one.

"No, actually, I can't see them at all. Tell us, what do they look like? Describe them to me."

He leaned forward in his plastic and metal chair, a small squeak coming from it. He propped his arms on the utility table that separated us from him and the portly armed county sheriff's deputy that stood directly behind him, ready to quell any impulsus Atticas that might come over him. He became even more animated.

"Ooh, Doc, they're about six inches high, they're green, of course (well, of course they are, I thought), they're bright green, there's four of 'em, no five of 'em, FIVE, Doc. They're marching in a straight line. They're looking at me and telling me to describe them to you. They tell me to use drugs and to break in places and steal stuff. They tell me all that."

"No, that was me that asked you to describe them," I said flatly. Funny. He was charged with breaking and entering, burglary, and a laundry list of other things. He had absolutely no previous psychiatric history. He had never set foot in a mental health center. He had never been hospitalized.

"Well, yea, but," he continued, "I think they're like, like, little leprechauns or somethin'. They're walking all over the place. You sure you can't see 'em?" he said, turning to try my partner this time. He raised his hands heavenward in a who am I to say gesture but said nothing. He didn't talk much, my fellow examiner.

We completed our examination in good CSI New York style, thanked the patient and the deputy, who had been trying his best not to lose it as he watched the man describe the St. Patrick's Day parade, and sent them on their way. After a break for a commercial (not really, but we had to get rid of some of the morning's coffee), we were back.

I looked at my fellow examiner, not saying a word but raising that same questioning eyebrow.

"FOS", he replied. He was nothing if not succinct.

(DISCLAIMER: FOS is not a real medical term, is not found in the DSM-IV TR, is not endorsed by the author of this blog, and was not suggested by the writers or producers of CSI New York or its affiliates)

I nodded.

He was right.

Your quickie primer on hallucinations:

Patients who have serious illnesses such as schizophrenia usually do NOT want to tell you about their auditory (such as voices) or visual (seeing things that are not there) hallucinations. They will do so if pressed, but will usually not volunteer this info. It is not fun for them, they are trying to ignore them or make them go away, and they are subject to the same stigma of being labelled "crazy" as anyone else.

These folks, even the ones who are really, really psychotic, RARELY see little green men who march across a table. I can count on less than five fingers the times I have seen a patient with true well-formed, specific visual hallucinations. If it is the first time I am seeing them, I am thinking about space occupying lesions in their brain more than I am considering dopamine dysregulation. These are the folks that get blown off in the ED with "new onset psychosis" and end up being diagnosed with a brain tumor.

If a patient tells you that his voices told him to find a 2003 Ford Explorer, hot wire the ignition, steal it, and use it as a getaway car in a bank robbery, please be suspicious. Voices are not that smart. They are not that organized. They do not plan well. They normally hang out in the background sounding like a low hum or a very loud beehive that will not go away. They interfere with your ability to go to parties and watch a whole movie in one sitting, but they do not force you to perform felonious acts. Go back to your attorney's office and come up with some defense that involves the ingestion of benzene or something a little more original.

Now, you can have hallucinations involving other senses as well. Some of the more classic presentations include:

Formication (OK, either get your glasses changed or get your mind out of the gutter or both). Folks who are having serious withdrawal form alcohol (delirium tremens or DTs) may have this feeling that makes them very antsy (ooh, I made a funny). Medications can cause this as well. Now, if you have been drinking heavily and fall asleep IN a fire ant bed, after which you are admitted to my crisis unit (real patient, no lie) this is NOT formication. This is severe insect chomping and stinging and requires massive doses of creams and sedatives. Yikes.

Smelling things that are not there (olfactory hallucinations) is not seen very often at all, at least in the circles I run in. Once again, if someone comes in and tells me that they smell a very strong scent of burning tires or sulfur, I start thinking temporal lobe brain tumor more than a primary psychiatric illness. Either that or they used too much floo powder (yes, that's spelled correctly too-jeez you people are picky) when flying in to see me from Hogwarts.

Gustatory hallucinations are also rare. Tasting bitterness on the tongue or feeling that there are small insects in the mouth or things like that are possible. A friend just emailed me about this very thing happening with her mother the other day. She is being worked up for the cause of her symptoms.

Suffice it to say that people who have real mental health issues and psychiatric problems most often do not want to broadcast them to the world. There is a lot of stigma out there, and just because you are psychotic does not mean that you don't have feelings. Legitimate symptoms usually come to the fore either through a history and physical examination, family reports, spousal observations, or directly from the person having them when they feel comfortable enough to disclose them. Other folks who "make up" bizarre and far out symptoms that they think will make them look "crazy" to an examiner, an attorney, or a judge are often trying to evade charges, relinquish responsibility for their own lives, or seek drugs that they do not really need.

By the way, I hope you have really enjoyed this blog post.

You were all so excited about it that you have learned about one other type of hallucination called a "collective hallucination".

You see, you have all imagined this post, fleshed it out, and filled in the details. I never wrote it. I'm sound asleep in my bed.

Good night, all. See you tomorrow.

Or not.

Pants on the Ground

2010-08-09T07:18:00.004-04:00

How can I tell if my patients are doing better, worse, or if there is no change evident despite my best efforts at treatment?

I can review their medical records, looking for changes in nursing notes, assessment tools, rating scales, or reports to staff.

I can attend staff meetings with other mental health care providers who may have worked with them the night before to see if any changes were noted on night shift.

I can talk to them, asking questions about symptoms and feelings and suicidal ideation.

Or....

I can just actively observe how they look. How they're dressed. Hairstyle. Makeup. FIngernail polish. Jewelry. Clothes.

One of the skills that has always been taught in medical school and in psychiatric residency programs is active observation. However, in this day of ten minute med check appointments, electronic medical records (read "The doctor never looked at me the whole appointment. Her eyes were on that laptop the whole time!") and symptom checklists, many young psychiatrists have lost the ability to just sit there, say nothing, and actively observe. It's a wonderful skill. How can I tell if my patients are doing well? I'll give you a few examples from the last twenty five years. These are, of course, amalgamations of signs that I have observed in real patients, but none of these are real patients in their own right. I'll give you the Cliff Notes version. Feel free to cut and paste into your favorite note-taking app or program for your own use.

Hairstyle:

"Don King" style usually mean manic symptoms are right around the corner, or that the hospital maintenance staff forgot (again) to put safety plugs in the electrical outlets.
Slicked back hair could mean that the vampire delusion is back, or that we have found the can of missing lard from the unit kitchen.
A completely slick, shiny, waxed, shaved pate means that we are having "King and I" week, that we are showing support for a loved one with cancer who has just had chemotherapy (don't laugh-this is a real one that I happen to think is pretty cool, actually), or that Sinead O'Connor has finally made it into treatment.

Makeup:

No makeup at all, just raw, tear-stained, pale-faced "this is me and nothing else" presentations usually mean depression. Not always, but I would certainly start there. Depressed folks don't give a rat's ass how they look, and they could care even less about how you see them.
Heavy application of powder, rouge, lip gloss, red lipstick, and eyeliner can mean that my patient is getting manic (quite common actually), that they have some type of mental retardation or deficiency and have never really learned the socially appropriate way to apply makeup in the first place, or that they are trying desperately to draw attention to themselves. If none of those is the case, then my John Doe admission from last night, the guy who looks vaguely familiar but who nobody can quite put their finger on, may actually be the lead singer from KISS or some joker impersonating Heath Ledger. The latter would be bad form, but I've seen worse.
Appropriate, tastefully applied makeup should mean that a person is feeling better and getting back to themselves. This is a very good sign, unless of course the tastefully made up person in front of you is a male, whereupon you might need to revisit your assessment and add gender identity disorder to your differential.

Fingernail polish and jewelry:

Runs the gamut. What is normal anymore?
Red nail polish warns of heightened sexual tension and increased energy levels. Coupled with bright red lipstick and Joker makeup, this will obviously let you know that a repeat lithium level is appropriate and that today's planned discharge might need to be reviewed with the team.
Black nail polish. Black Widow fantasies. (Always have a female chaperone in the room during these interviews). Tendency to Green Day music. Henry Ford lover. (You can have any color you want as long as it is black).
Heavy silver and turquoise jewelry: you are practicing in the Colorado. This is normal. Move along.
Piercings. OMG. You used to see these in one spot, usually the lip or on one eyebrow. Now, they are in the belly button, on the cheek, in the nose, and through the tongue. Length of hospital stay is directly proportional to number of piercings added WHILE on the inpatient unit. Does not apply to outpatients or those with black nail polish. See Green Day reference above.

Clothing:

This one's easy.
Bright colors: Mood good, supply of high quality detergent and fabric softener adequate. Watch for mania.
Dark colors or dressed completely in black: depression is really, really bad OR teenager rebelling against parent OR see Green Day reference above OR search possessions for Johnny Cash music OR you have inadvertently been interviewing a roadie for Shania Twain.
Lastly, length of hem and cuffing on pants is key.
Pants hemmed way too high or rolled up to half calf length denote: mania, impending strike of Category Five hurricane (only for Gulf Coast practitioners), exhibitionist with a leg fetish.
Pants on the ground: depression, defiance, lack of belt. Check for protrusion of underwear up over pants at what would be the belt line if the patient had a belt. If no belt, give a firm talking-to and apply wedgie maneuver (be sure to document for JCAHCO and CARF, as this could be considered abuse or harassment in some states).

See? Simple, yes. I can assess all these things without saying a word. Powers of observation are key.

What have YOU noticed lately about how physical appearance and dress gives us clues into how a person is doing?

Psychiatry A to Z: Grief

2010-08-08T22:22:00.003-04:00

"Your father has collapsed."

The call comes at the worst time possible. My mother-in-law is moving into a new house, we are moving into her house, we need to pack, someone needs to watch the kids.

"I don't know. Your mother is with him. They're taking him to the hospital now. I don't know."

I am in the car in what feels like minutes. I don't think I even take a toothbrush, although I really don't remember.

"Call and let me know as soon as you find out something. We'll be fine here. Go."

"Take all the time you need. We'll cover things here. Don't worry. You need to be with your mother. Go."

Racing down the interstate in slow motion. Time flying by as it stands stock still. Tears and prayers and more prayers and more tears and time flying by.

"Don't you die on me. Don't you die before I get there. Hang on until I get there." There are still so many things unsaid. The scenery blurs, clears, blurs, clears, blurs, clears. Is it raining outside? No, it is raining inside. Come in out of the rain. I can't. I'm getting soaked. "Don't you dare die on me."

The time in the hospital is a blur. The waiting room. The ICU. The doctor. The staff with their kind eyes and kinder manner. My mother is broken. My brother is angry. They were so close to making it all better. So close. I have the knowledge but not the will. Decisions to make.

"We can make him better. We can rebuild him." A part of my brain laughs hysterically at the thought of the television reference, so stark against the sunshiny darkness of his bed. Beep, beep, beep. We can never rebuild him. I have seen the scans. They show me because I am a doctor. I see the vast whiteness in his brain. Clean, pure, permanent. I know what this means. I do not want to be a doctor. Oh, God, not now.

I try to support my mother as we walk up the aisle in the church. I see little. I remember little. His mother, my grandmother. "Oh, parents are not supposed to outlive their children. Oh." We travel. We talk and eat and "Oh, how your children have grown and I remember when your Daddy..." They put him in the ground. It is hot. Why do people die in the summer, that hysterical part of my brain laughs, way off in the distance. It laughs and laughs so that it will not cry. They put him in the ground. My little sister is there, off to his side. Others are already there waiting for him. Waiting for all of us, I think. It is so hot and the hole in my chest is so huge that I cannot get enough air. I am drowning in the middle Georgia sunshine.

Six days later I am working in an air conditioned emotional bubble. I do what I know how to do the best I know how to do it.

Six months later, I open my closet door and see the stack of papers there on the floor beside the filing cabinet. Odd, I think. That's not like me. I sit down and go through them, filing and getting things back in order. I feel like I have just awakened from a half year's dream. No. A nightmare.

Six years later, I think about him every day. Every. Single. Day. It is not unpleasant, but it is painful. The scar over the huge chest wound is thin and tenuous, but it holds.

Now, I think about him from time to time. When change jingles in my pocket, or when someone mispronounces a word the way he did, I smile. When I hold my granddaughter in my arms, the way he held his the day he died, I feel proud. He is here with me. He will always be with me.

As my mother once described it, I am not happy with what happened, but I am content.

This is grief.

This is life.

Psychiatry A to Z: Facilities

2010-08-07T21:37:00.002-04:00

Have you ever needed to visit the facilities?

No, I'm not talking about the public restrooms off some tourist exit on I-95, or the huge dank open shower room at that KOA Kampground your family went to every summer when you were a kid.

I'm talking about facilities where you can get the mental health assessment and psychiatric treatment you need. Have you ever visited one of these? If you became depressed or anxious or started to hear voices, would you know where to go to get help? This sixth installment of Psychiatry A to Z is going to give you some idea about exactly where you can go if you ever need help. Those of you who already know this drill will have a chance to help the newbies in the comments section at the end of the post, so don't be shy!

I'm going to approach this in what I truly hope will be an easy to understand way. If you need help, what (or who) do you often think of first?

Your primary care physician (family doctor, internist, or even your pediatrician if you are a child or teenager) is usually the doctor who knows the most about you. He or she (I'll use he from now on in this post to make it simpler-please don't hate me) has treated you for ear infections, heartburn, pneumonia, back pain, headaches, stomach ulcers, and all sort of other ailments that he got you through with flying colors. This may be a surprise to you, but your family doctor probably knows a pretty good deal about many common psychiatric illness, including depression, anxiety, panic attacks and unresolved grief. He may, if he chooses and if you agree, be able to diagnose your ailment and start treatment without ever referring you out to a specialist, just as he might treat some heart ailments without sending you to a cardiologist. If this is the case, you are very lucky! You can get excellent treatment from a person you already know and trust, who knows a lot about you, your primary illnesses, your medications, your allergies and other important details about your life. How easy could that be? Your primary stop is your primary care provider's office or clinic.

Now, some of you probably do not go to a primary care doctor, or you may not even have one. You do, however, visit your allergist or your OB-GYN or your neurologist for everything from migraine to uterine fibroids to eczema. These doctors also have varying levels of comfort with diagnosing and treating illnesses that may not be in their primary purview, but that they have seen hundreds or even thousands of times in their careers. Cardiologists are often the first line provider who works up someone who presents at the office with panic attacks, a fairly severe manifestation of anxiety that can be quite debilitating to sufferers. If the cardiologist is astute and a good listener, he can save you time and hundreds of dollars in charges for unnecessary tests to rule out heart disease where none exists. Panic attacks often make healthy people think that they are having a heart attack or even that they are dying. Of course, most healthy thirty somethings with chest pain that is coming from severe anxiety are certainly not going to die from it, but they will feel much better if that anxiety is treated. So, your second line of defense can sometimes be your specialist's office. Once again, they know you well, there is already a relationship there, and you are more likely to open up and get to the real problem at hand in that setting.

A third place that you might receive mental health services is your local emergency department. This is actually not a bad place to go if you are truly in a crisis situation. If you have severe side effects on a Saturday morning, for example, from a medication that your doctor started you on that Thursday before, and his office is closed, the ED is the safest place for you to get an immediate assessment and any care that you might need. Another true emergency situation in psychiatry is someone who is suicidal, has a plan to hurt themselves, has the means to carry out that plan, and is determined to die. Often times, the ED is the fastest route to care. The doctors and staff there may not know you as well as your own doctor, but they have the capability to marshall vast resources to help you. My primary job nowadays is to see people with mental health problems and complaints who come to emergency departments all across the state. Telepsychiatry is fast, easy, efficient and gets people connected to the help they need right away.

A fourth option for care is to see a psychiatrist in an office setting. This can be something that you set up on your own by calling for an appointment, or you might be referred by one of the three places that we have already talked about above. (Remember that there are many types of providers out there, but that I am writing specifically about psychiatric care since I am a practicing psychiatrist.) A psychiatrist might see you in a mental health clinic, a private office, a VA mental health clinic, or a not for profit center. He might specialize in psychoanalysis, counseling, medication checks and management , or electroconvulsive therapy. He might see you as often as once a week or as little as once every six months, depending on your diagnosis, symptoms, or personal goals for treatment. Note that psychiatrists are trained as medical doctors, so they have gone to medical school for four years and have done at least another four years (often more) in residency training dealing specifically with treatment of mental disorders. The settings you see a psychiatrist in may be (but do not have to be) more medically oriented that other settings you might visit.

We're not quite done! What if the problems you are experiencing are just a little too severe to be handled and treated in an outpatient setting? There are a few more options for you there as well, and like the ones we've visited so far, they are graduated in intensity and overall level of care, as well as how restrictive they might be when it comes to your personal freedoms or ability to come and go at will.

First, you might be referred to a day treatment program, day hospital or other hybridized setting. These programs and facilities are more intense than med checks or counseling sessions, often take place for several hours each day, and are often based in a hospital environment to take advantage of the facilities and amenities there. These are normally volunteer programs. You might attend one of these for as little as one week or as much as several months.

Next step up might be a voluntary admission to a psychiatric or mental health hospital. No, thank goodness, most modern hospitals do NOT look like the one that Jack Nicholson went to in One Flew Over the Cuckoo's Nest. They are clean, reasonably furnished (not like being at home, but not uncomfortable), are staffed round the clock and offer things like adjunct therapies, groups and even AA or NA meetings. Admission to some inpatient units can be as short as three to five days (crisis units) or as long as several months or even years (some of the older psychoanalytically based hospitals that take patients for extended periods of treatment for severe disorders). When I was a chief resident in psychiatry years ago and did the screening for admissions to our academic teaching unit, I used to ask prospective patients if they could stay with us for several weeks. Now, insurance companies and other reviewers want patients in and out of inpatient facilities in a matter of days.

Finally, if things are extremely severe, with symptoms that are out of control or the possibility of imminent harm to the person or someone around them or a significant inability to care for yourself, involuntary admission (commitment) may lead to a hospitalization against your will. I pray that most of my readers have never had this happen to them and never will, but some of you may have experienced this. It can be fairly traumatic, with handcuffs on your wrists (depending on your local law enforcement's rules about such things), a ride in the back of a police car, and an admission to a locked unit with few freedoms at least for the first assessment and observation period. These facilities were always the most frightening to me even as a trainee or later on as a faculty member at a medical school, because the locks on every door and the strict policies and procedures reminded you constantly of how ill the residents of those facilities were and how they desperately needed excellent care to recover and get back to their lives.

I have tried to give you a step by step walk through of the types of settings and facilities that exist today to uncover, assess, diagnose and treat mental illness, from the simplest brief episode of anxiety to the most severe psychotic disorders. I hope that this has given you something to think about, or that it has helped you understand some of the situations that you, your spouse, or other family members or friends may have found themselves in when they needed to access mental health care.

Have you or someone you know had experiences, positive or negative, in any of these facilities or settings that you could share?

Psychiatry A to Z: Exercise

2010-08-04T17:19:00.002-04:00

E, my friends, is for exercise.

I don't want all of these Psychiatry A to Z posts to be about depression and drugs and painful tests and things that go bump in the night. I decided that this one would be more light and upbeat. More positive. Maybe even more fun!

We have already covered assessment of mental illness, such as when you go into a doctor's office for the first time. We have talked about addictions and crises and other scary things, and you have left many very astute and wonderful comments about these issues. I want you to know that sometimes, believe it or not, sometimes you may receive a suggestion or even a prescription for exercise as part of your treatment regimen. This is obviously a good idea for ANY mental health issue you may be having, but may be especially helpful if you battle depression or anxiety.

Why exercise as part of this series? Because I have seen first hand in the last week or two how preventative medicine and prescribing an active lifestyle is a positive way to promote good mental as well as physical health in all of us. Beside going for regular screening exams and getting blood work and all of those things we discussed earlier in the week, exercise can be a great way to help yourself in several ways:

1) One theory for the benefit of exercise is that exercise triggers the production of endorphins. These are natural opiates that are chemically similar to morphine. They may be produced in response to the effort that the body expends during exercise. Studies show that the body's metabolism of endorphins is complex, so there are likely additional mechanisms involved in the mental health effects of exercise as well.

2) Animal studies have found that exercise increases levels of serotonin, dopamine and norepinephrine in the brain. These neurotransmitters have been associated with elevated mood, and it is thought that antidepressant medications also work by boosting these chemicals. Other complex chemical such as brain derived neurotrophic factor (BDNF) may also be increased in exercise. These may lead to improved cell health and longevity.

3) Exercise, when combined with a healthy diet, may lead to weight loss, toning of muscles, and a general overall feeling of wellbeing that goes beyond the physical and affects the way we feel emotionally as well.

Now, I have heard all the excuses you will undoubtedly come up with, many from my patients and some out of my own mouth. Before you start hitting me with the "yes, buts", let me just say this.

Various guidelines, from folks like the American College of Sports Medicine, say that for protective benefits and health maintenance we only have to exercise for thirty minutes a day, five days per week. For me, that's a nice moderately paced walk around the local college campus on a beautiful summer evening after the sun has gone down. The temp is moderate, the pace is moderate and the benefits are measurable. If you don't like walking, there are swimming, biking, aerobics at the local Y, or many other activities depending on your tastes.

The bottom line is, physical exercise makes us feel good. It improves our mood. It makes us look better and feel more confident. Who doesn't want all of those things, right?

Over the years, the older patients I've cared for, including some that were in their eighties and beyond, have shared some of their secrets with me. Everyone is different, of course, but these folks all say some of the same things. Eat right, get enough sleep, find activities that keep you busy and make you happy, and...

KEEP MOVING.

Psychiatry A to Z: Disability

2010-08-04T00:15:00.001-04:00

We were twenty-nine minutes into a thirty-minute new patient interview. I had asked all the usual questions, gotten most of the usual answers, and was ready to wrap it up. This thirty-nine year old female obviously had a diagnosis of bipolar disorder, most recent episode depressed. Her symptoms were moderate and easily approached with some limited counseling and a trial of standard medications. She did not need to be hospitalized. She had no substance abuse issues. In other words, she had a fairly common disorder with a fairly common presentation that needed a fairly common approach and would lead to fairly common outcome. This was the kind of patient I loved to see, because she had a diagnosis that was treatable. She would get better and she would have a good quality of life. That should make us both happy, right?

Then it happened.

She bent over at the waist from her seated position and went for her purse.

Oh, God, no. Not today, please!

Her hand reached into the cavernous Walmart bag (no, it did not come from Walmart. It WAS a Walmart bag).

Please, God. I have a wife. Children. Please...

Rustling. More rustling.

I'll do anything. ANYTHING. I promise I'll never eat another chocolate covered creme filled doughnut ever again.

She came back up for air, red-faced and huffing a little bit, a sheaf of official looking papers clenched in her hand like Esau's birthright.

Nooooooooooooooooooooo..........my brain screamed in a silent lament.

And then, right then, at one second after thirty minutes into her very first appointment EVER with me, she uttered these words. The most terrifying words a doctor can hear from a brand new patient.

"Doctor, I just need you to fill out these forms for me if you don't mind."

I know what these forms are. They are of the Devil himself. They are Jabba the Hut forms. They are papers that, once accepted and filled out, will dog the doctor for the rest of his and his patent's life. For you see, they will propagate and multiply and get infinitely more wordy and their fonts will get infinitely more tiny so that the poor aging doctor, running out of time and eyesight, will become psychotic trying to remember what he put on the first one or the forty-first one that also need to be carried over to the sixty-second one.

These, my friends, are disability papers.

Certification papers.

Golden tickets.

The Holy Grail sought by those who would be permanently attached to the government trough for the rest of their natural lives.

"I see. When do they need to be completed?"

"By five o'clock this afternoon, Doctor."

She smiles sweetly. She calls me Doctor. I can hear the capital D in her voice. It is now 4:02 PM. She extends her (oh my God the pain in this shoulder is just so intense it makes me suicidally depressed) arm and there they are, suspended in the void between doctor and patient like low-hanging fruit.

"You realize that this is the first time I've ever seen you, and only for thirty minutes," I say, trailing off lamely, knowing that if I touch these papers, if I take them and hold them in my hand, I will set off a cascade of giant rolling balls and poisonous darts and falling masonry the likes of which has not been seen the Raiders of the Lost Ark.

"I know you can (cough) help me (sputter), Doctor." The damn capital D again.

I take the papers ("Wipe that smile off your face and run, Indy, run!"), set them down on my desk, and bid her goodbye until next time. I know that what I write on these papers, if the powers that be can read them (hey, Montezuma's Revenge got nothin' on a scorned doctor with terrible handwriting), will not be to her liking. You see, this lady, like many psychiatric patients I see, is not disabled. Not by a long shot. Allow me to explain.

I see many, many patients who have various psychiatric disorders. These range from anxiety to depression to alcohol and drug problems to schizophrenia to personality disorders to dementia. These disorders, while very real and very onerous for the patient and the family, are usually illnesses that can be diagnosed, treated, and managed quite well. As I am fond of telling my patients, you can live quite well with this illness and have an excellent quality of life in spite of it. That is, if you WANT to. There's the rub.

The vast majority of psychiatric illnesses, though diagnosable in the DSM IV because of certain symptom clusters and levels of impairment in functioning, do not cause complete and permanent disability, something that folks often want me to say they have on the forms they bring to me. They are ill, yes. They need ongoing, sometimes lifetime treatment, yes. But are they so disabled that they cannot leave their homes, shop for their own groceries, volunteer at a local church, or maybe even work part time? Most of the time, no. If you read these forms, especially the ones like the forgiveness of student loan forms, the criteria on the back are extremely specific. Most people, even with diagnosed and serious mental illnesses, do not meet them. When I return these forms to them unsigned or with negative responses on them, I am sometimes met with anger, frustration, and even malignant entitlement.

I look at it this way.

If you are truly so mentally sick that you cannot function, I have seen you for many years and know that for a fact, you are invested in treatment so that you can function at the very highest level possible, and you need the assistance of the disability system to help provide you with income to live on or to get the medical care you need, I will do anything in the world in my power to help you. Anything.

On the other hand, if you are young, reasonably healthy physically, pop in and out of treatment every year or two, or when you lawyer tells you you should come in, and "manufacture" symptoms that make you look sicker than you really are, then I have no time or sympathy for you. Shame on you. Find your true potential and embrace it. Work if you can. Do you know how much better your overall mental health will be if you have a meaningful job to get up and go to even a few times each week? Do you know how much better you will feel about yourself?

If your chief complaint is "My lawyer told me I needed to come here to help my disability application", you are wasting your time.

If you give me a laundry list of symptoms right out of the DSM IV because you have memorized them or someone has coached you on what to say, you are wasting your time.

If you come up with symptoms like "I see little green aliens with purple shoes and lollipops in their mouths" because you think that makes you look really crazy, you are wasting your time. (Number of patients with that particular symptom cluster that I have seen in almost thirty years of practice? Zero)

If you think, after it took me decades to pay off my own low interest student loans, that I will take away your financial obligations to the government with a stroke of my pen because you "don't really get enough sleep most nights", you are wasting your time.

How much better could all that wasted time be used in trying to assess your true emotional and physical needs, coming up with a working treatment plan to address them, and living your life to the best of your ability?

A good friend and colleague once told me about his own approach to his patients who tried to convince him they were disabled when they were truly not. His method? He loaned them a copy of the movie The Elephant Man with these instructions.

"Go home and watch this movie. Watch it all and pay attention. Then, if you think you are as disabled as the main character in the movie, make an appointment to come back to see me and we'll talk about your disability application. If not, you can just send the movie back to me and I will close your chart."

My friend, as you can imagine, received most copies of his movie back in the afternoon mail.

What do you think constitutes true disability, either physical or mental?

Psychiatry A to Z: Crisis

2010-08-02T12:18:00.001-04:00

"He WILL see my child, and he will see her NOW, " bellowed the large woman from the waiting room up front. I could hear her from my office in the back hallway. She was that loud.

"My daughter is hallucinatin' and she is wantin' to be killin' herself and he WILL see her and help her. I will go right up that street to the television station if I have to. I will call the state director if I have to. You tell him that!" Point well taken. No need to walk all the way back here to tell me. I got it. I already had a schedule packed with patients from 9 AM until 5 PM, including lunch, but I heard her loud and clear.

This lady and her young daughter, a cute little girl of ten with hair in braids and a serious affect that belonged on someone much older, were in crisis. The little girl was indeed hallucinating, hearing voices that told her she was stupid and that she should kill herself. The mother was frantic, beside herself, so anxious about the safety of her child that she was in full protective mama bear mode. She was going to do whatever it took to get something done to help her daughter.

Now, first off, I was always taught from medical school all the way through residency that the emergency is defined by the patient. I still believe to this day that this is true to a very large extent. When someone is poised on the side of a bridge and threatening to jump off, they have set the stage for a true emergency. When someone leaves a suicide note and drives off to a secluded spot in the nearby woods, loaded pistol beside them on the front seat of the car, they have laid down the gauntlet and given fair warning to all who will look that they are in crisis. When a teenager with brittle diabetes and bipolar disorder stops taking her insulin and is repeatedly sexually promiscuous, she is telling us that she is in crisis and needs some type of intervention.

If you tell me that you are in crisis, I am going to take you at your word. I'm going to get you into the office or the ED or the crisis clinic or the admissions unit, and I'm going to help you sort all of it out. I'm going to talk to you, or to your family or friends if you're too agitated to speak with me. I'm going to evaluate the nature of your emergency, your crisis, and see what I can do. Now, that being said, one of several things might happen at that point.

First, I might agree with you one hundred per cent. The emergency is real. The crisis is imminent. The threat is credible. If this is the case, I might move to counsel you, medicate you, or offer you voluntary admission. If things are really out of hand and you cannot make good decisions on your own behalf and you are an imminent danger to yourself or others, I might be forced to admit you against your will. Often, even when someone is hurting terribly and on the verge of committing suicide, they will challenge me. "You can't keep me here. I'm fine. I want to go home. You don't have the power to hold me." Sorry, but in that case, I do. I can hold you for observation or send you to a hospital for involuntary treatment. Crisis means action.

Secondly, I might agree that the situation or the problem is urgent or even emergent, but not a crisis that requires immediate action. Assessment can be more leisurely. There is time to gather corroborative history. Medical records can be searched for and reviewed. We have the luxury in that case of letting you cool down and defuse the situation a little bit. As long as you are in a secure place and you're safe, the actions taken do not have to be so immediate.

Lastly, I might not agree that this is a true crisis or emergency at all. After listening to you and completing an adequate assessment, I might decide that this is something that can wait until the next morning, the next day, or even the next week for a routine appointment. It is problematic enough to require intervention, but it is certainly not a crisis.

All that being said, remember how we started this discussion out? The patient initially defines the emergency or the crisis. If it feels like the world is going to end, your life is over, or you can't live in this world anymore, then a proper assessment of those feelings and that situation must be done. I have no choice there. My job is to evaluate each person and each set of circumstances on their own merits, not stereotyping or pigeon holing them based on a preconceived set of notions or criteria. If I can just remember that, we're both better off and you get the excellent care you need and deserve.

So, what happened to the little girl and her mother? I worked her in right away, spoke with her and her mother, made some minor medication adjustments, gave mom some much needed reassurance that she was doing a good job with her daughter, and sent them on their way. I realized that the mother was not angry with me. She was scared silly about her daughter's frightening symptoms and she knew I would be able to help. She wanted to see me. All I needed to do was to want to see them too.

In psychiatry and mental health, the crisis is defined by the patient. Doctors would do well to remember that and respond accordingly.

Have you ever been in crisis? Did you seek help? Was it given?

Psychiatry A to Z: Benzos

2010-08-01T15:47:00.004-04:00

OK, we might as well jump right in and get this one out of the way.

Benzodiazepines are not bad drugs. You may not recognize this term, but you would know what they were if I mentioned several of them by name: Valium, Librium, Xanax, Ativan, Serax, and Klonopin are probably more familiar to you. These drugs can be short, intermediate, or long acting. They all bind to the benzodiazepine receptor in the brain, and they enhance the effect of a neurotransmitter called GABA. What does this mean to you?

Well, benzodiazepines can be extremely useful in the treatment of muscle spasms and stiffness that come from various neurological diseases. They may be used in the management of seizure disorders. They may be helpful when trying to sedate someone for a diagnostic test or a surgical procedure. They may be helpful short term sleep aids when you just can't get your rest at night. They are still used in some settings to treat acute withdrawal from alcohol. Finally, they are also pretty darned good medications for anxiety.

Ah, there's the rub, isn't it? These medications are SO good at what they do that sometimes people go a little overboard with them. They might take an extra one some nights to help them sleep when one just didn't do the trick. They might take them every four hours instead of every six as prescribed because their anxiety is just a little more severe this month and "I know the doctor wouldn't mind." They might share them with other members of their family or their friends, and then discover that there is too much month left for the number of pills left in their bottle. Taking too many of these types of medications over time leads to "tolerance", a physical state in which your body has become physically dependent on a certain amount of this drug circulating in your system most all of the time. If that level drops, you most likely will experience withdrawal symptoms that may be mild to severe and even life threatening. This does not mean you are a bad person. It just means that you're physically dependent on the medication. Some patients who have chronic physical or emotional illnesses may take very stable doses of benzodiazepines under a doctor's care for months or even years and do fine. It is important to remember that when your body is in this physically dependent state, it is always unwise to just stop taking the medication cold turkey. This must be done by tapering the drug over time, and once again should be done under medical supervision for safety.

Addiction is different from physical dependence. When one is taking a stable dose of Xanax 2 mg three times a day for a severe panic disorder and doing fine, there is no problem. When one takes more pills than the doctor prescribes, shops around for more than one doctor to provide more pills to take, forges prescriptions to get more drug, or buys pills off the street to supplement the prescriptions that the doctor has already written, that is almost always evidence of addiction and IS a problem. Folks who are addicted may take three or four or ten times the usual dose of a drug, sometimes taking up to ten or fifteen mg of Xanax a day or more. This can also be accompanied by the abuse of other drugs such narcotics, street drugs,, or alcohol as well, which compounds the problem. When someone is addicted to drugs, they may lie, cheat or steal their way to more drugs so that they can "score" what they need to keep their habit going. We may talk more about addiction in a later post in this series.

So, the bottom line is, used correctly these drugs are very helpful to a lot of people for a lot of different physical and mental conditions. The problem is that many doctors, primary care and internal medicine and surgery among them, are spooked by all the potential problems with benzos and may not want to prescribe them at all, even when they are most likely the drugs of choice and would do very well for the patent. I am now going to tell you some things that guide my own use of these drugs in my own various practice settings. These are tips, red flags, catch phrases, excuses, and more that always make me think twice about whether or not I want to prescribe a benzodiazepine for a patient or whether I look for something different or better suited.

First of all, if I have known you for many years, have made a diagnosis myself of something like panic disorder and have been successfully treating you with a benzo for many years, I am likely to continue to do so. Taking a stable, moderate dose of Ativan or Xanax is most likely safe, effective, and less expensive for you than some other options at our disposal.

If you begin to overuse your meds, even innocently, because your symptoms have changed, please come talk to me about that and we
will work on that problem together. A simple dosage adjustment or change in agent may do the trick. If you do not tell me and I see prescription requests coming earlier and earlier, I will begin to be suspicious and will be much more likely not to prescribe for you.

Do NOT play doctor and decide when it's time to double your dose or change the time of day your dose comes or things like that. Do NOT assume that I will be OK with whatever you decide to so. You are the patient and I am the doctor and we MUST work as a team to get your treatment right. It is, after all, my license and DEA registration on the line when I prescribe controlled drugs. I will guard that jealously.

Do NOT share your medication with your spouse, your sibling, your mother, or your friends across town. I have prescribed these controlled medications for YOU- nobody else. If I find that I am being made the default source of drugs for anyone else, that is one of the quickest ways to make sure my pen goes back in my pocket and never comes out for you again.

In that same vein, if I find that someone has forged my name on a prescription for controlled drugs and has taken that forged document to the pharmacy to have it filled, my first and last call on that person's behalf will be to the police. Trust me on this one. I have no qualms about having someone arrested when they have violated my trust to that degree. And just in case you're wondering, yes, I have had to do this before.

If you are coming to my office to convince me that your pills ran out three weeks early, please be creative in your presentation to me. I like to be entertained but I do not like to be toyed with or bored. I have heard all the excuses that are old standards, so work on your delivery before you see me. If I hear that you dropped all your pills down the sink for the fifth time, that's a problem. If you tell me that your dog ate them, I will most likely ask you why chihuahuas only eat Xanax and not Lisinopril or Motrin, which you also have bottles of at home. If you tell me that someone broke into your house and stole only your bottle of 10 mg Valium and left the wad of cash on your dresser untouched, I will be skeptical.

Please don't come to my office and soften me up with a long convoluted story about your bipolar disorder and then say the following: " I have taken every antidepressant ever made and lithium and Tegretol and Lamictal and all the antipsychotics and everything you could use. The ONLY thing that ever helps me is the blue bars, you know, the totem poles. I must have those in the 2 mg strength and I must take them six times a day with an extra dose just in case every day. Plus, I really need you to give me a three month prescription with a year's worth of refills. I will look at you like you have lost your ever loving mind and will most likely terminate the interview within forty five seconds. You are not a soul who is hurting and suffering and looking for anything that we can do together to get you better (which is my goal and should also be yours). You are looking for drugs in all the wrong places. You will not get them from me.

Finally, I like to consider myself a fairly intelligent, compassionate guy. I went into medicine, after all, because I wanted to help people. If you come to me with an open mind, looking for some solutions to your problems that we will both be satisfied with, I will work right along side you to accomplish that. If, on the other hand, you are demanding, hostile, threatening and manipulative, I will show you the door. When it comes to benzodiazepines, the last ditch argument often goes something like this.

"Well, I don't understand why you would withhold the one thing that makes me feel good. Why won't you give me Valium? I stopped drinking ten days ago and I will never drink again. I don't know why you would be worried about that at all. I need my Valium."

Followed by: "Well, if you won't give me what I want and what I need, you're just forcing me to go out and get it on the street I guess. It's your fault that I'll have to buy it on the street. Or I'll just go to Dr. Jones and he'll give it me if you won't."

Please.

Spare me.

Once again, benzodiazepines prescribed and used correctly are wonderful drugs for many varied physical and emotional conditions. Used judiciously they can be very helpful in the overall management of these disorders. They can also be abused and lead to substantial addiction problems.

When you come to ask me for benzos, I would just ask that you not tell me that you ran over your last bottle of Valium with a steamroller, when you and I know you drive a Toyota.

Do you have any stories about benzodiazepines, good or bad? I'd love to hear them!

Psychiatry A to Z: Assessment

2010-07-31T20:07:00.002-04:00

The depression has gotten the best of you. It is winning.

You're sad all the time, you don't eat or sleep well, you have no interest in anything pleasurable, and you can't focus. You've even begun to look at death as a reasonable alternative to the hell that you're living day to day. You decide that you just can't take it anymore. Your family has been trying to get you to seek help for weeks. Now, you see that it's one or the other. Kill yourself and be done with it, or pick up the phone and call someone and get some help. One look at the picture of your kids on the end table by the sofa helps you make up your mind.

"So now what?" you ask yourself aloud.

This series of blog posts will deal with the "now what?" question in some detail, from the initial call to specific treatments to prognostic issues and concerns. Since I am a psychiatrist by training and trade, I will reserve the right to deal with this information from a psychiatric point of view. This does not mean that there are not dozens if not hundreds of other assessment methods, treatment paradigms, and outcome measures out there. There most certainly are, and many of them serve patients admirably. It also does not mean that by using terms like "patient" that I am forcing everyone into a predetermined sick role. I am not doing so. I am simply using the terminology I was trained with and that I am most comfortable using today. Please know that I am not so much trying to leave things out but include important things from my day to day psychiatric world view that I think might help your understanding of the process as it winds through my head in certain situations. Know also that these blog posts are not intended to be therapeutic interventions or direct advice to anyone on their own specific circumstances. For that, you must follow some of what we will discuss in the rest of this post about access and assessment and work with your own personal provider to deal with issues of importance to you. So much for disclaimers!

The first thing you must do is call. Most psychiatrists have receptionists, answering machines, or answering services that will take your call, initial information, and help you make an initial appointment for an assessment with the psychiatrist. Now, granted, this process will be different if you go to see a private doctor versus a state mental health center versus a VA doctor, etc. Know this: they will all want to know basic information about you. This will include things like your name, age, work status, insurance information, who referred you, and the main reason you want to see the doctor. Once you have given them this info and they have given you an appointment time, you're ready to go.

On the day of your appointment, please have a general idea of where you are going, where the parking is, and how you get into the psychiatrist's office. Know these things before the actual appointment day if at all possible. You should strive to get to the office at least fifteen to thirty minutes early on your first visit. Why? They will want you to fill out a set of paperwork that gets even more information from you about your general condition, your previous and ongoing medical and mental health treatment, your insurance coverage, and the like. All this is preamble to your actual visit with the psychiatrist. The office staff may weigh you, check your height, or ask you to fill out a standard screening instrument for things like depression or anxiety. These are all pieces of the puzzle that will help the psychiatrist know you better and help you with your problem. Another reason for being on time to a psychiatrist's office is that they see patients on a fixed schedule (usually) and all they can bill for to generate their livelihood is their time. Very few psychiatrists do procedures or run labs or things like that, so their interaction with patients is their work and their living. Respect that by showing up on time for your appointment and expecting that the psychiatrist will be ready to see you at that appointed time. There may be emergencies that preclude that on some days, but they should be extremely rare.

Now, it's five minutes before your first appointment with this person you've never met who you think is going to lay you down on a Victorian couch and suck every last bit of knowledge and emotion and experience from your brain. Relax! Psychiatrists are people too! He is most likely looking forward to meeting you, especially if this is your first visit. He is not going to sit behind you with a pad and pen like all those New Yorker cartoons, stroking his beard and asking you to tell him more stories about your mother. He is not going to shoot you full of truth serum to hear about your darkest sexual fantasies, and he is most certainly not going to smash electrodes onto your head and do electroconvulsive therapy right then and there on the floor. Heavens no!

The psychiatrist, depending on his practice focus and style, will most likely want to simply talk to you on this first visit, asking lots of questions about what brought you to see him, what your background is, a little about your past medical history, your past mental health history, your past medications, and things of that nature. He will indeed ask about any pertinent family history, work and social history and any medical problems that might have some bearing on your presenting issue with him. He will most likely ask about your alcohol and drug use, sexual history and orientation, and other very personal issues that most people would never ask you. This is not because he is nosey or a voyeur, but because he needs as complete a picture of your life as possible to be able to help you. Lastly, he may ask you a number of questions that seem silly to you or even insulting to your intelligence. He might ask if you know the complete date or if you can count backwards from one hundred by sevens or if you can name the last five presidents. These are all items that are part of what is called the mental status examination, designed to assess your attention, concentration, fund of knowledge, and reasoning abilities. These are questions that he would ask any new patient to some degree, so don't feel put upon or singled out because these feel odd to you.

Before you know it, anywhere from thirty minutes to an hour has gone by in a flash and you are almost done with your first appointment with the psychiatrist. You are still in one piece and none the worse for wear! The last thing that the psychiatrist may do is to briefly discuss his preliminary impressions with you. He might talk about a working diagnosis if he is not absolutely sure what you are dealing with. He might recommend medications to treat your symptoms. He might ask if you'd like to enter counseling to discuss some of your painful issues. He might give you a lab slip to get some blood tests done, or he might refer you for cognitive or psychological testing with a colleague. All of this is so that the two of you are together on what it is that you are there for, what the psychiatrist thinks the medical diagnosis is, and what treatments he is prescribing to treat you and get you back to your old self. There is really no magic here. Accurate gathering of information, complete history taking, and appropriate prescription of therapies all help you along the path to recovery from your mental health problem. A good psychiatrist, though he may grow to know you well and enjoy seeing you, is always happy to see the day that you no longer need him and can go about your life on your own. That is what makes him happy.

See? There is nothing magical or frightening about a psychiatric assessment. It is your first step toward treatment, recovery and a happy life.

How does this fit with what you have heard about or experienced yourself when seeing a psychiatrist for the first time?

Psychiatry A to Z

2010-07-31T18:05:00.002-04:00

OK.

You and I are going to embark on a new, exciting journey. We're going to make a pact, you and I, to see this project through. It will take a number of weeks to complete, and it may be start and stop at times, but we can do it together. Are you in? Oh, you want to know the details first? OK, I guess that's only fair.

We are going to explore psychiatry, pulling no punches and sparing no feelings (including mine), by looking at it A to Z. I already have several topics in mind that I think you might like to hear about. I will start with those. Of course, we will start with A. The cool thing about this is, I would like it to be interactive. I would like you to put your two cents in if you think of a topic that might interest the broad range of folks who pop in and read this blog from Australia to California to The United Kingdom. You may do that by emailing me at Gesmithmd2@gmail.com and telling me about your idea or topic. Though I will not be able to use all of them, I promise to work as many of them in as I can in the twenty six installments allotted to this project.

So, to get us started, I am going to tell you about Assessment.

What happens when you ring up a psychiatrist's office or a mental health center and ask for an appointment?

Check back right here to get the answer. I will announce availability of posts on Twitter and Facebook as I always do as soon as they are ready for your perusal.

Check your bags, buckle your seatbelt, and hang on.
Here comes Psychiatry A to Z. I hope you enjoy it.

Dr. S

Do You Need Me?

2010-07-21T07:11:00.004-04:00

I'm often asked the question, "When should somebody go to see a psychiatrist?"

There are a few broad brush types of situations in which a trained mental health professional like a psychiatrist may be able to help you. Now, before I go any further, I need to make a couple of things clear to you, since a lot of people also ask about these issues as well.

A psychologist is a mental health professional who is trained to assess and treat psychological problems and issues, as well as do certain types of testing, diagnostic interviews, and therapies. Psychologists are often called "Dr." and often have higher level degrees such as PhDs. This of course stands for Doctor of Philosophy, from the Latin. Psychologists have done higher level training, but have not attended medical school.

Psychiatrists are also trained mental health professionals who also happen to be medical doctors. That is, they have attended medical school and have either an MD or a DO degree. They usually have a four year college degree, have gone to medical school for another four years, and then have completed a residency in psychiatry that is an additional four years of training.

Of course, there are many other trained professionals such as pastoral counselors, nurses, nurse practitioners, masters level therapists and others who are more than willing and able to help you with a wide variety of emotional issues and problems. We all work as a team, and each of us brings a different set of skills to the table when assessing, diagnosing and treating mental health issues.

Now, back to the original point of this post. When do you need to, or when should you, seek the help of a psychiatrist?

Your family doctor, who knows you well and treats you for a variety of ailments from colds to heart attacks, is often the perfect person to help you assess your need for psychiatric help. If he has diagnosed a major depressive disorder, for instance, he may have prescribed an antidepressant medication such as Zoloft or Pristiq or Wellbutrin to help your symptoms. If you take this medication, see the doctor back for follow up, and things are better, great! If not, your doctor may try another medication or two that he is familiar with to help you. If things simply do not get better, he may speak with you about a referral to a counselor or a psychiatrist or both to step up the intensity of the treatment a bit. That is a perfectly appropriate time to go see a psychiatrist. Your family doctor may have certain psychiatrists that he likes to refer to, or he may simply help you find the right person to see.

Another time that you may need to see a psychiatrist is if you are feeling suicidal. Anxiety and depression are common, but not everyone's illness progresses to the point that they are seriously contemplating killing themselves. When it gets to that point, you don't want to bide your time and hope that things get better. They might, but again they might get worse, and then it may be even harder for you to take the steps you need to get help. If you are feeling hopeless, helpless, sad, and are thinking that taking your own life is the only way out for you, then you need to seek help immediately. Go to your own doctor for a referral, call a psychiatrist directly, or go to the local emergency department for help. Don't wait. Your life may depend on it.

Lastly, if there is ever a time when you feel that things are looking strange, odd, out of context, or if you just feel you are not distinguishing between what's real and what's not, then you may be experiencing psychotic symptoms or psychosis. (From the Greek for "giving life to animation"). This can be a terrifying time when you feel that other people are watching you, that you are being threatened, or that others can read your thoughts. You may think that a television show has special messages embedded in it that are directed towards you. You may have terrifying auditory or visual hallucinations where you hear voices speaking to you or see things that are not really there. Obviously, this can be a true psychiatric emergency, just as feeling suicidal can. In this case as well, seeking help as soon as possible will enable a professional to assess the problem, make a diagnosis and start appropriate treatment right away.

These situations (severe worsening depression, suicidal ideation and psychosis) are only three of the issues that a psychiatrist may be able to help you with. If you experience any of them, please seek help immediately and get the treatment you need.

Secrets in the Addict

2010-07-18T12:25:00.002-04:00

I was visiting a primary care office in a small South Carolina town a few months back, and the clinic doctor was telling me how he was the resident expert on substance abuse for the little town.

"Oh, it's not because I want to be, but there's just no other place for folks to get the help they need around here. We do what we can," he told me as he wolfed down his fifteen minute lunch.

"How do you balance the needs of your regular patients with the alcoholics and addicts who come in demanding pills and spinning tales for you?" I asked, genuinely curious.

"Oh, it's quite simple," he said between mouthfuls of sandwich. "I have a scripted spiel that I give all of them at the very first of the very first visit." He looked up at me, a twinkle in his eye.

"Yes, I want to hear about your technique!" I said, answering the unasked question.

"it's brilliantly simple, actually, " he said, wiping the mayonnaise from the corner of his mouth. "As part of my guidelines for treating substance abuse and dependence, I tell that I am brutally honest. I have three principles that guide my interactions with them and my treatment of their illnesses."

I waited patiently, sitting on my hands so as to not reach for an insanely large oatmeal raisin cookie that taunted me at arms length.

"Number one: all addicts lie. I tell them this up front. I know it's true; they know it's true. When that's out of the way, we're over the first big hurdle."

"Number two: I will do everything in my power to help you with your disease. Medicines, AA, NA, referrals for detox, long term programs, whatever you need, I'll help you get to it, find it, sign up for it, and complete it." He reached for the cookie I was now ignoring, but broke off only half of it, offering me the other half. I shook my head from side to side and thanked him for the offer.

"Number three: I don't want to hear it! Whatever the excuse is for today, whatever the reason you lost your prescription this time, whatever the reason is for missing so many AA meetings, I do not want to hear it. Why?"

We both smiled.

"Refer to Number one?" I asked.

"Exactly"" he thundered, standing up and tossing an uneaten quarter of the oatmeal cookie in the trash can.

"It's been a pleasure chatting with you," he said, shaking my hand vigorously. "Got to run!"

And with that, he was out the door and on to his afternoon clinic.

Lost. Truly Lost.

2010-05-27T15:34:00.004-04:00

I was asked to see him because he was a danger to himself.

A little younger than me, he looked ten years older, grizzled and gray with deeply tanned leather for skin and bright, white-hot coals for eyes. He was angry, make no mistake about that. Angry at his family for arguing and angry at the government for not fixing things and angry at the economy for laying him off work.

"It's hard, you know, when you don't have enough change in your pocket to buy yourself a cold drink on a hot day."

They kept arguing and fussing and fighting and getting on each others' nerves to the point that he couldn't take it any more. He could not stand to see his sister's teen aged children talk back to her and belittle her.

"They got no manners at all. You shouldn't be allowed to sass your mother that way. I couldn't listen to it no more."

He didn't know where to turn. He felt helpless. So he decided to get a length of rope from his workshop, tie it to a rafter, make a noose out of the other end, and put it around his neck. As he was preparing to step off the countertop he had climbed onto, someone came in and found him, poised and ready. They called 911 and off to the emergency department he went.

We established pretty quickly that it was not his intention to die. This had been an impulsive action, never planned. He had no previous attempts. There were no alcohol or drugs involved.

"I thought if I did something like this that they would stop the fighting, that the attention would be put on something else for awhile."

As we talked about possible interventions, treatments, applications for vocational help, and other community resources, his face reddened. Soon he began to cry.

"I can't read or write," he offered, clearly embarrassed.

All my talk of counseling, clinics, and referrals was not helping him. It was scaring him to death. He saw paperwork and computers and offices as frightening places, places where he was lost. Truly lost.

At that moment, I was reminded yet again of what my job is. Strip away the cell phones and computers and high definition monitors and telecommunication equipment. Make a connection, a real connection, with a real person. Meet him where he is. Hear what he is saying. Provide what he needs. Help him.

"Would you like me to get you in to see a counselor and somebody who can start teaching you to read and write?" I asked, smiling.

He smiled back, a smile made more sparkling by the tears that still coursed down his leathery cheeks.

"Yeah, I sure would Doc. I sure would."

Inside a Fourteen Year Old Brain

2010-05-24T08:00:00.000-04:00

Inside a fourteen year old's brain:

I don't care what they think about it. She is the only girl for me. I love her with all my heart. I feel things for her that I've never felt for anybody before. I love her. I love her. I love her. I hate her. How could she do this to me? She can't laugh at me like that. She can't make fun of me in front of all of my friends. And my parents, oh, Jesus H. Christ, my parents, I mean how dense can they really be? I was just, oh my God, I was just, I mean, Jeeeez, how could they SAY things like that? I wish they woud just go away or stay in the den and never talk to me again. I wish they would just leave me alone. I wish I could leave, just run away and never come back. I could do it. I could. I could grab some clothes and a steal a little money from my dad's wallet, just enough so he wouldn't miss it right away. I could hop a bus to Texas or something and then call her and get her out there with me and get a job and find a place to live and she could come out there and nobody would bother us and we'd finally be alone and happy and....but shit! She just flirted with that guy tonight at the taco place and she looked like she liked it and shit! What was I supposed to think? What did she think I would think? What was I supposed to do? I wish my hair was longer aad down in my face. I wonder if she saw the tattoo. Christ, it's got her birthdate on it and everything. If we break up I've got this crappy tattoo with her name on my arm and Jeeeesus, what will I...

Psychiatrist: "Mike? I'm Dr. Smith. Could you tell me what brought you to the emergency room tonight?"

Fourteen year old Mike, head hanging low, no eye contact: "Nothin."

Random Thoughts About Work

2010-04-08T08:46:00.001-04:00

Random Thoughts about Work

I drive out to the sixties-era psychiatric hospital I trained in back in the 1980s. I flash my laminated badge at the guard shack, make a left hand turn, navigate the perimeter road and pull into the parking lot beside the old geriatric unit I had attended team meetings in as a wet-behind-the-ears senior medical student. Today, I will make rounds as a senior psychiatrist working along side a team of nurses, physician extenders, counselors and others in charge of the treatment of sixteen acutely ill patients with psychiatric and substance abuse disorders in need of crisis treatment.

It's always strange "going home" to the place I trained and serving in a different capacity, no matter how many years have gone by and how much experience is under my belt. The drive is the same, the grounds are the same, the old buildings look the same outside, and it almost feels like I'm being transported back in time to those same old training days with their associated anxieties and challenges. Of course, it's not the same. I am more confident, I know my craft, and I am in the position of diagnosing and treating my own patients, not simply observing my mentors. For almost thirty years now, I have thoroughly enjoyed the interactions I have with patients, the backbone of a psychiatric practice. The basic structured diagnostic interview with a new patent has not changed that much since I was a psychiatric intern. I was trained to listen, observe, diagnose and treat. The advent of so many new treatments and medications has made my job more gratifying and my interventions more helpful to many people who suffer with mental illnesses.

One thing that has not changed is the lack of support, financially and otherwise, of the existing mental health treatment system. This is especially true of the inpatient side, where patients are admitted and treated for anywhere from three days (such as in the crisis unit I visited today) to several weeks in the state hospital facilities that remain open. The number of mental health hospital beds in the state of South Carolina has fallen precipitously since I began practicing in the eighties. The condition of many of the facilities is poor indeed, and the morale of the staff appears to fade and darken along with the building facades. Inside the buildings, such as the one I worked in today, the paint is dingy and peeling, the furniture is spartan and makes a dorm room look inviting, and the food service is adequate at best. Creature comforts are few and far between, with repeat screenings of old movies through older VCRs the norm for evening activities. One has to wonder how a depressed, suicidal patient, already feeling hopeless and negative about the world, perceives this environment to which she is being subjected in the name of "treatment".

Politicians, corporations, churches, families, and others may feel that if these people with mental illnesses are out of sight, then they will go away. They can rationalize traumatic handcuffing and transport from emergency department to crisis unit as humane and safe for all involved.They can justify old, worn furnishings as necessary for budgetary reasons and "because they won't be here for very long anyway".
They can try to do all these things, but I am here to tell them that people with mental illness have feelings just like the rest of us. They know when someone is there to check on them, or just to get a check. They understand the difference between a staff member charting a few lines to finish a shift or helping them chart a new course through a debilitating psychotic episode. They feel the acute difference between someone coming in just to do a job, and someone who is not satisfied until the job of helping them recover from their illness is complete.

I am a smart, well-trained psychiatrist. Politicians and those who hold the purse strings that fund and drive treatment are talented people with big agendas.We think we have it all figured out, that it's all under control. We feel smug, confident and justified in what we are about. We play our cards close to the vest, and we play to win.

Patients, even when they are the most depressed, manic, or psychotic, have our number. They know where our true feelings lie. Are we sending them the message that we intend to broadcast? Are we being truthful with them?

Are we being truthful with ourselves?

Telepsychiatry: Part Six: The Future?

2010-03-31T07:00:00.000-04:00

We have discussed various aspects of telepsychiatry over the last five installments of this series. We come to the end of something that is in fact only the beginning.

What is the future of this technology and this treatment modality in mental health and in the medical specialty of psychiatry? I will offer an opinion from the vantage point of an experienced doctor who has practiced psychiatry in various mental health settings from private practice to the VA system to state mental health departments to local county jails for the last twenty-three years.

As this system is being used in South Carolina now, as previously discussed, we are able to see mental health patients in the emergency departments of the state that have no regular coverage, thus providing quality mental health assessments with a much shorter wait time than before the program started. Patients who might have been detained on legal papers for days or even weeks waiting for hospital beds that are in ever dwindling supply may now be treated aggressively and perhaps even released from the ED to pursue outpatient treatment. Emergency department resources are freed up for other medical emergencies such as myocardial infarctions or diabetic ketoacidosis.

There are other ways that the technology may be used to offset decreasing funds, personnel and resources. Outlying mental health centers that do not have the luxury of a full time onsite psychiatrist may be able to contract for telepsychiatry time to see not only emergency patients but their regular patients who otherwise might wait months for a routine medication follow up with a doctor. Telepsychiatry clinics may become more commonplace in the years to come, as funding for physicians, travel time, and facilities may continue to be cut by state legislatures.

To combat the isolation discussed in Part Five, The Disconnects, more telepsychiatry linkages may provide time and technology for telepsychiatrists to have virtual staff meetings to discuss problems, present interesting and challenging cases and management suggestions, and have time for peer review of their work. Again, the isolative nature of the work precludes the old “sidewalk” consults with colleagues across the hall that have always been great learning experiences of us as we grow in practice experience.

I hope you have enjoyed this six part series on telepsychiatry. Please check back here soon for other musings and opinions offered by a psychiatrist who would love to know that he provides a little something for you to help pass your time, learn something new, and think about things in our world.

Telepsychiatry: Part Five: The Disconnects

2010-03-29T07:00:00.000-04:00

This is the fifth part of a six part series on telepsychiatry. I have written so far about why telepsychiatry has its place in SC in the treatment of those who suffer from mental illness. I have talked about the setup used to make this intervention happen and the patients who benefit from it. I have spoken about the types of connections that are made every day through telepsychiatry.

This post will talk a little about the disconnects that arise from doing mental health work from afar through the magic of video monitors and computers. There are several.

First, the job of telepsychiatry by default is one that allows me to talk to my patients and be with them without really being with them. I was schooled in a psychiatry training program that emphasized the restraint of any kind of physical contact between psychiatrist and patient, so I have always been used to the maintenance of personal boundaries. However, maintaining personal space has never meant being in a different room or even in a different part of the state as I am now when speaking with someone in an emergency department. The technology we use is so good that one often forgets that there is a screen in front of you as you talk. Still, the lack of close personal contact in the same room is a true physical disconnect that is emotionally challenging.

Another disconnect is the lack of continuity of care once a consult is completed and sent back to the requesting physician. At times I might speak directly with the ED staff to get background information about a person or to ask about medical issues or other concerns prior to seeing the patient. After reviewing that, doing the interview, making my diagnosis and recommending treatment, I send the electronic consult back and that ends my involvement in the flow of treatment. There are exceptions, of course, such as when I am asked to reconsult on a patient who has stayed in the hospital ED waiting for an inpatient bed that might take several days to open up. In those cases, I will be able to review what has happened since my first contact with the patient and make further recommendations based on any changes since that initial examination.

A third and very important disconnect is the physical and emotional isolation for the telepsychiatrist. Working from eight to sixteen hours at a time, alone, can be physically, intellectually, and emotionally isolating for the doctor. Once again, there are regular contacts by telephone, email and videoconference throughout a shift, but this is a radical change for a doctor like myself who has moved from over twenty years of direct clinical work, along with personnel administration, meetings, and supervision of staff, to working literally on my own for hours at a time with no other people in the immediate area. Great care must be taken to maintain stimulation through use of onsite CME, email, reading literature, periodic telephone contact with others and the like. I will speak to this issue a bit more in the last part of this series, Telepsychiatry: The Future.

Next up: Telepsychiatry: The Future. This will be the last installment of this six part series. See you back here on Wednesday.

Telepsychiatry: Part Four: The Connections

2010-03-26T07:00:00.003-04:00

There are several types of connections in telepsychiatry. This blog post will help you understand some of them and how they impact the provision of psychiatric services through this new medium.

The first is obviously the physical connection between the parties involved in a telepsychiatry consult. I have previously talked about the process of getting a telepsychiatry consult, reviewing information, interviewing the patient, and sending a report back to the requesting emergency department (ED) in the second post in this series. This process involves communication on several levels. The first is electronic. This system involves the use of encrypted, secure communication through an electronic medical record system that is able to send requests, append additional information at a later date (such as labs that might come back after the initial interview), and provide secure feedback of recommendations to the requesting ED. Access to multiple databases provides invaluable information about diagnosis, current medications, adherence to a prescribed treatment plan, appearance at scheduled appointments, and use or abuse of prescription medications. These electronic connections provide the backbone of the system, in that without information, we are flying blind.

Another connection involves an older piece of office equipment that still has its place in the modern office: the telephone. Even after I have reviewed information, sent the “start consult” message electronically to the hospital ED and am ready to see the patient, I make it a point to call the staff and tell them that I am ready to go. This insures that they know I am ready to do the consult, lets them know which office to dial into (we have multiple sites around the state where doctors work their shifts), and allows me to speak with the charge nurse, the attending physician, or the nurse assigned to that patient to get any extra, last minute information that might be critical in doing the consult. I have had doctors repeat the entire history and presentation of the patient to me over the phone, even though I have already reviewed it all electronically, because they are used to sharing this information one on one with a trusted colleague they have called for help. This little connection, actually speaking to the folks on the other end of the consult process, humanizes it and makes it more real to them. Remember, this is a relatively new procedure in psychiatry and mental health, and healthcare workers are still just a little freaked out by rolling me around on a cart and watching and hearing me talk to them on a television screen from hundreds of miles away! After the consult is over, I may speak directly to the ED staff again if there is something that I want to make sure they understand clearly.

The third connection is with the patient. I have already alluded to this in Part Three: The Patients in this series. I have been amazed at how easy it has been to “enter” a patient’s room in the ED and talk to them just as if I were actually there. Most start talking to me very easily, just as they would in the office. It seems that it may actually be a little easier to divulge some sensitive information in this setting, in that it is not as physically intimidating as sitting three feet away from another person. I have a had a couple of patients who were so paranoid that they could not get past the fact of the physical camera setup in the room, bringing the whole interview process to a screeching halt. One lady asked me over and over again, “Are you IN there? Are you really IN that screen?” Others think that the process is so wondrous that they just sit and smile the whole time we are talking. Still others have gone as far as reaching out to shake my hand at the end of the interview, smiling as they realize that this is not physically possible.

A fourth connection is the support that we as clinicians get from our personnel who administer the grants that fund the project, the staff who process the information gleaned as we do our work, the SCDMH staff who support this ongoing work, and the IT staff who are on call twenty four hours every day to help if there is a hardware or software glitch. None of the actual clinical work that we do every day could be accomplished if there were no support at the top administrative levels of the Department of Mental Health. The staff in Columbia who track our every move, review the work logs that we email to them every night, scour the reports for problems and look for potential solutions are invaluable. IT staff have helped me make connections with a hospital in the middle of the night when cameras and lines and electronics were just not going to cooperate with me no matter what I tried. All of these folks are part of a great team that is providing timely mental health care to those in South Carolina who need it but might not be able to access it any other way.

Finally, a note to my contemporary Pat Barta, @patbarta on Twitter, who is also blazing his own trail in telepsychiatry through the use of Skype and other systems in Maryland. Even though we have all of these expensive systems in place and there is a lot of the “gee whiz” factor in telepsychiatry, we still send reports through a fax server, and they still end up getting printed out on paper to a little fax machine in the corner of the ED in many cases. We are still not green enough! I certainly hope that with the continued adoption of a nation wide electronic medical record system that we will one day get away from our dependence on paper and all the time, effort and space that it takes up!

Next up: Telepsychiatry Part Five: The Disconnects.

See you back here next week.

Telepsychiatry Part Three: The Patients

2010-03-24T07:00:00.001-04:00

What kind of patients do I see when doing telepsychiatry? The short answer is: all kinds!

The usual suspects all show up, but with a twist. This is emergency room, or as they say nowadays, emergency department (ED) work. All kinds of people come to the ED for all sorts of reasons. Allow me to share just a few of the more interesting ones with you.

I have already seen children and adolescents who end up in front of the camera because of academic, family, or substance abuse related problems. These can be kids from age eight to eighteen. They have often had a falling out with a boyfriend or girlfriend and after the argument feel that their world is going to end. They decide that they will kill themselves, but not before they tell someone (usually a parent) what’s going down. In true twenty first century fashion, I have heard how these kids send a text message, yes, you heard me right, a text message, to Mom or Dad and tell them, in 140 characters or less, that life as they know it is over. Not a standard issue suicide note, but a text message. Can you believe it? Yes, you can if you have been the parent of a kid currently younger than twenty. The kids think nothing of it. This is their version of the electronic “cry for help” that you’ve heard about, and it should be taken very seriously. Some parents feel absolutely out of control with these children. They feel that with Facebook and Twitter and LinkedIn and My Space and texting and tweeting and messaging that they have no control over anything in their child’s universe. They forget who the parent is and who is actually calling the shots. Often times, once the parents are empowered and the kids know that the ED staff (including the consulting psychiatrist) are on the side of the parents, the ballgame is over. Decisions are made, consequences are discussed, limits are set and all is set right again.

Folks looking for substances often amble into the ED with complaints of pain, injury, renal stones, falls, bruises, or other assorted problems that can only be cured (in their minds) by large doses of narcotics or sedatives. These are the people that don’t mess around. They tell you exactly how many pills of what color, shape and size will dull their toothache or their back pain or their psychic pain. They go to great lengths to convince you that they have a high tolerance for painkillers, that they must take at least four times the standard dose or “it’s just like eating candy”. They look and sound pitiful until they realize that you’ve heard it all before and you’re not at all impressed or convinced. The psychiatrist that they thought would be their supplier is now just one more roadblock between them and the Oxycontin or the Xanax or the Percocet. Then, the sweet, pain-filled smile and artfully interjected grimace become a mask of pure unadulterated anger that leaps out at you through the camera almost as if you were there. “If you won’t give them to me, then tell them to discharge me and I’ll just have to get them off the street!” they roar. “What happened to the suicidal thoughts, the plans to hang yourself from the tree out back?” you ask firmly. “Oh, I’m not going to do that, I didn’t mean that,” they stammer, knowing that you’re on to them and wanting to terminate this interview as soon as possible. Many of these folks are not interested in assessment, diagnosis or treatment. They come to the ED with a specific objective in mind. If you, the consultant, are not part of their solution, then you’re part of their problem, and they are done with you. Nothing personal, of course.

A third interesting group of folks that show up in the ED are the elderly. Especially the older, eighty-ish white male who comes in with plans to kill himself with one of the twelve guns that he owns and knows full well how to load and shoot. This unusually pleasant, friendly, intelligent, resourceful man has often been widowed for a year or two after a marriage of forty or fifty or even sixty years. He labored for a large corporation or a plant or a township for most of his working life, was loyal and trustworthy and had a great work ethic. He was the sole caretaker for his bride, who he watched slowly dwindle over ten or twelve years after she was diagnosed with Alzheimer’s Disease and its associated dementia. He still lives in the family home they shared for half a century, has a full equipped workshop and shed outside, has a new pickup truck and a chocolate lab at home, but he has no joy in his life any more. He labors to get up each day after a fitful night of half-sleep. He eats microwave meals. He socializes little. Many of his friends have passed on. His children have lives of their own and he “doesn’t want to burden them” with his own cares. He has decided to withdraw most of the cash that he has saved up in his checking account, clean and oil one of his guns, get in his truck and drive southwest until he runs out of gas and money. Then, wherever he ends up, he will find a quiet place to park, he will load that gun, and he will end his own life. Quickly, quietly, and alone, far from family and home.

I have seen this teenager, this substance abuser and this pleasant elderly gentleman through my telepsychiatry camera. I have spoken with them and reasoned with them and tried to help them see that life is indeed worth living. I have tried to instill, even through a lens and a computer, a little hope. I have reached out through that camera over tens or even hundreds of miles and have tried to make a connection that will save a life. Sometimes I think I am very successful. Sometimes I am not.

It’s all worth it, though, when that young child’s parents feel empowered and can take their offspring home to a safe, nurturing environment and tell me before they go, “You know, if I could reach through there and shake your hand, I sure would!”

It’s all worth it when that angry person looking for pain killers gives NA a second chance and his sponsor another call.

It’s worth it when that old gentleman, who just hours before thought that the barrel of an oiled gun was his best friend, can look me in the eye and say, “You know, it helps just to talk to you.”

That, my friends, is what it’s all about.

Next up? Telepsychiatry Part Four: The Connections, on Friday, March 26th. See you back right here.

Telepsychiatry Part Two: The Setup

2010-03-22T07:47:00.000-04:00

When I tell people that I am a telepsychiatry consultant, I get a lot of blank stares. Few people know what telepsychiatry is, much less how it is set up and exactly what the equipment looks like. I get a kick out of the pharmaceutical reps who have called on me for years asking when they can “drop some samples by” or come by to see me, as they have been so used to doing for so long. I explain to them that I no longer write prescriptions myself, but that I make recommendations to the emergency room physicians about medications that might be helpful in a particular case. When they then insist on coming by to see me, I tell then that it would be fine as long as they show up between 12 midnight and 1 AM, when I am wrapping up my evening shift’s duties. Then, the light of understanding usually shines from their eyes.

So, how does one do telepsychiatry? I will try to make this as simple as possible while giving you and idea of how the whole thing works. First of all, I work from a regular office in the same mental health center building I was in as Medical Director for the last ten years. Picture if you will: on my left at about nine o’clock there is a laptop computer, encrypted and specially set up for this particular job. I leave it at the office all the time, and this is the only reason it has for existing right now. At the ten o’clock position is a regular Brother fax machine/copier/scanner. At the high noon position is a large high definition monitor attached to a Polycom HDX 4000 machine that sits just behind it. This is the visual interface of the system, allowing me to see and talk to the patients that might come to me from Myrtle Beach or Greenville or Easley. At one o’clock is usually my personal MacBook and iPhone setup, on which I write notes, work with my calendar, and the like. To the right of that is a standard office telephone.

All work comes in through the South Carolina Department of Mental Health electronic medical record system, a secure way of communicating back and forth about patients and their needs. On receiving electronic notification of a consult, I review the information sent by the hospital, which can run from five to twenty five pages depending on the problem at hand. I can then access three other databases if necessary to glean other information about past history, hospital admissions, mental health center treatments, and other information that might be of assistance, as I get ready to talk to the patient. When my review of the background information is complete, I then set up my electronic medical record note, at the same time generating a fax that lets the hospital know that I am ready to see the patient. I usually call the hospital ED as well, just to let them know verbally that I’m ready to start the consult.

Once the hospital knows that we’re good to go, they mobilize a telepsychiatry cart that resides in each hospital emergency department that participates in the project. It looks a little like a cross between a computer on wheels and a robot, with a large HD screen of its own and a swiveling camera on top. When it is activated and moved into a special room where the patient has been brought to see me, the patient can see me on the screen. On my end, I can see the patient in a large screen and myself in a smaller, picture-in-picture screen up in the corner. I can control both cameras with my remote control, turning from side to side and zooming in and out as needed. Picture quality is phenomenal, and the sound quality is also excellent. I have found that most patients take to this medium very well indeed (more on this in Part 3). After just a few short minutes, one forgets that the monitor surrounds your picture, and it really seems that you are just sitting there talking to each other as you would in a regular office. There is a very slight lag time after speaking, so it’s necessary for me to wait just a split second longer than usual speech to make the conversation flow well. Patients usually do not catch on to this very well, so it is up to the clinician to modulate the conversation.

Once the conversation is done, I sign off, cutting off the live feed. I then complete the electronic consult on the laptop, click on a fax button, and the fax server sends the completed consult off to the ED doctor who requested it. Of course, there have been times when I will need to talk to family members, hospital staff or others in order to get the whole picture of what is going on. All in all, once the consult is faxed, that’s it!

Come back Wednesday, March 24th, for Telepsychiatry Part Three: The Patients.

See you then.

Telepsychiatry Part One: Why Now?

2010-03-19T07:40:00.002-04:00

Why now?

Why, in this age of technology that artificially connects us with virtual friends and disconnects our real time interactions with friends and family, would the mental health profession want to use telepsychiatry to reach out to those with no mental health resources? Why indeed?

Psychiatry (and mental health) has always been the redheaded stepchild of medicine. Founded on principles that were considered scientific by some and quackery by others, characterized by barbaric procedures such as induction of insulin coma, cold-water baths or isolation chairs, this terribly interesting part of medicine has had its share of detractors through the years. We have progressed to treatments as varied as electroconvulsive therapy (made infamous in most minds by Jack Nicholson in One Flew Over the Cuckoo’s Nest), psychoanalysis, cognitive behavioral therapy, and now the “new” psychopharmacology that takes advantage of our knowledge of neurotransmitter and receptor pharmacology to design “smarter” drugs that target specific areas of the brain while leaving other more side-effect prone areas alone. There are still practitioners of “talk therapies”, but because of decreasing insurance reimbursement and ever-shortening time slots for each patient interaction, many psychiatrists have switched gears to doing more medication management and psychopharmacological management of their patients, trusting that medication therapies can fix or at least ameliorate the mania, depression and psychosis that plague many of our patients.

In spite of all of these changes over the last twenty five years or more, one aspect of mental health treatment still stands out as the primary necessary interaction between practitioner and patient that cannot be totally jettisoned. The psychiatrist still has to speak with his patient. He needs to talk to her, interact with her, and read her facial expressions. He needs to watch her mannerisms, gauge her level of paranoia, and assess her posture and body language. He needs to see whether or not the antipsychotic medication she has taken for the last month is causing the tremor she is now complaining of, or if the restlessness she feels all day long is part of her illness or akathisia, a common side effect of some psychiatric drugs. To do all these things, he needs to sit with her and talk with her and see her, in person. These types of assessments just cannot be done over the telephone or by email or through text messages.

There are several modern day problems that get in the way of the efficient and effective practice of psychiatry. One that looms large in this time of increasing budget woes for the states and the country as a whole is cost. There are few places in the country any more where someone can come into a psychiatrist’s office and be seen for a full hour of therapy and medication management for less than $150-250 dollars. Many offices that still provide this kind of access only accept cash payments from patients. Many do not even attempt to file insurance, but leave this complicated chore to the patient herself. With the economy as it is, insurance benefits decreasing, and the pressures of raising families and paying the mortgage, many patients who need care simply cannot afford it.

In the past, some of these patients would then migrate to the public side of the treatment arena, opting to go to local mental health centers for what was always considered “minimal” or even substandard care. They would see a case manager, maybe a nurse, and rarely a doctor. Treatment would be minimal but helpful. The largess of the states was always a fail-safe for the public mental health system. Money would always be there and budgets would remain fairly constant. Of course, now that old saw is no longer valid, as states struggle to cut already bare bones budgets yet again, and the infirm and sick feel the weight of lack of funds as budgets are balanced squarely on their backs. Patients have begun showing up in emergency rooms across the country, in some places increasing their visits as much as four hundred per cent in the last five years. Others get picked up on random legal charges and get carted to jail, while still others are incarcerated for longer terms in the nation’s prison system. While the running joke used to be that the Los Angeles County Jail was the country’s largest psychiatric hospital, now states such as South Carolina can also ruefully say that their county jail and prison systems may treat more chronically mentally ill patients than the state mental health system does.

Enter telepsychiatry.

In partnership with The Duke Endowment, the South Carolina Hospital Association and hospitals around the state, a new telepsychiatry project was begun in the fall of 2007. Details of this program can be found through links on the website for the South Carolina Department of Mental Health. The program now serves patients in the emergency departments of seventeen hospitals around the state, with more coming on soon and a target of anywhere from 45-60 hospitals before the program is fully implemented. Patients vary from children and adolescents to geriatric aged patients, and diagnoses also run the gamut from depression to substance abuse to delirium. Why now? How is this program making an impact in the state of South Carolina and its provision of mental health services? How can its success be measured?

I will be exploring this topic in more depth in the next five installments in this series on telepsychiatry. Please check back often as we discuss the following areas:

2) Telepsychiatry: The Setup
3) Telepsychiatry: The Patients
4) Telepsychiatry: The Connections
5) Telepsychiatry: The Disconnects
6) Telepsychiatry: The Future?

I will look forward to sharing some insights into this fascinating new area of service provision with you, and I welcome your comments and feedback. Please feel free to comment directly on the blog site, or email me at Gesmithmd2@gmail.com.

See you back here on Monday, March 22nd for Part 2: Telepsychiatry: The Setup

Client versus Consumer versus Patient: What's in a Name?

2010-03-18T11:28:00.005-04:00

There has been an ongoing debate for what seems like years now about how to address people who have mental illnesses. Notice I did NOT say "what to call them". People who suffer from and with mental illnesses every day are not the illnesses themselves. They are people, just like you and me, who live and love and work and play. They just happen to have bouts of depression, mania, psychosis, suicidal ideation, or any number of other mental health problems that once begun, seem to be hard to eradicate completely in most cases. But I digress.

When I started medical school in 1979 (yes, Virginia, I AM officially middle aged now, for sure), the sick people that I talked to and examined and drew blood from and started IVs on were all called patients. Now, granted, they had names and I tried from the very beginning to call them Mr. So and So or Miss Something, but to me, and to all my mentors and teachers and peers, these folks were still patients. They had come to the clinics or hospital or emergency rooms where I did my training and they came for one specific reason (though it manifested in many different forms). They were sick and they wanted to feel better. They wanted to relate a history, be examined by a knowledgeable practitioner of the healing arts, have some tests done, get a diagnosis, and be prescribed a treatment plan. These people were patients. They did not mind having that label attached to them. They did not feel stigmatized by it. They did not feel demeaned or put in a one-down position versus the doctor that was trying to help them feel better. They knew that doctors treated patients who were ill and wanted to be cured. Where did that term come from in the beginning? Middle English/Old French/Latin verb pati, suffering.

Enter the politically correct crowd, which I must say (and this will get me lots of hate texts/email/mail I'm sure) has to include the otherwise well-meaning mental health advocacy groups. They and others began to feel, and to preach, that patients were being demeaned and discriminated against just by being called patients. Really? They had late night strategy sessions trying to decide what would be more humane and soft and fuzzy and pleasing and non-discriminatory to patients and their families and friends. They came up with warm fuzzies like client, person with mental illness, and my all time favorite, consumer of mental health services. Excuse me? Last time I checked, clients went to attorneys to seek legal advice and consumers were the targets of witty ads selling soft drinks during the Super Bowl. Consumers? Really?

Now, excuse me for standing on my blogging soap box for one more minute, but I see absolutely NOTHING wrong with the name or designation patient. I trained to be a doctor, a physician, a healer, a first-do-no-harm kind of guy. I see people who are hurting, in pain, suffering. They are patients who come to a doctor to be diagnosed, treated, and maybe even healed, though in mental health we certainly have a long way to go on that front even in 2010. They are not my clients, nor do I want them to be. They do not consume products and services that I dispense to them out of a vending machine. We work as a team, doctor and patient. Each of us is smart, savvy, and motivated to get a good result. I cannot do it alone, without my patient's cooperation and help as I try to make him or her well.

The diseases, yes I said diseases, that I treat every day do not act in a politically correct way. They are not soft, warm, nice, or fuzzy. They do not afflict less people if they are called a "nicer" name. They are not less deadly if they are verbally euthanized. Depression will affect one in six people in this country over a lifetime. Schizophrenia affects one percent of the whole population, striking its deadly blow in the prime of a person's life. Borderline personality disorder leads to a completed suicide rate that is staggering. Alcoholism and drug abuse and dependence are rampant in the state of South Carolina and the nation as a whole. The soft peddlers want us to believe that these disorders play nice if we call them nice names. They want us to believe that if we allow one drug such as marijuana to be a recreational pastime like watching baseball, then the dependence on crystal methamphetamine or crack cocaine or narcotics will just go away or not be as big as problem as it is now.

They are wrong. These diseases rob the patients who suffer from them of their health, safety, happiness and livelihoods. These disease kill the patients who suffer from them, especially if they get inadequate or no treatment at all.

As a practicing psychiatrist for over twenty three years now, I am sounding the alarm for anyone who cares to hear it. Do not underestimate and dumb down the epidemic of mental illness that we are grappling with in this country today. Do not sanitize the diagnosis and treatment of mental illness by calling these folks consumers of mental health services as if they were trying to decide which laundry detergent to buy. Acknowledge these devastating illnesses for what they are, call those who suffer from them patients, advocate for better treatment, fund initiatives for better access and better mental health care, and let's get on with the business of diagnosing early and correctly, treating aggressively with evidence-based therapies, and reaching for the remission that our patients so desperately want and deserve.

Efficient AND Effective

2009-11-08T07:10:00.004-05:00

OK, here's something that's just been rattling around in my brain for a few weeks. How do hard work and a long list of things to do really get done, and why do some difficult tasks satisfy while others just frustrate?

As many of you know, I'm a fan of productivity writing and systems and software and books and all things related to it. I study them, I try them out, I add a system or a method and see how it works for six months or a year, then I ditch it and try another one until it feels right. I think that's the key. It has to feel right. Some systems make you feel that the productivity police are always on your shoulder and in your briefcase or on your desktop, and you start to feel watched and monitored all the time. Not good for free form productivity. Other systems let you go with the flow and do it as it happens and make it up as you go along. Some give you lists of points and rules and actions and outlines that box you in. At each extreme lie the bookends of frustration and boredom, both giant killers when it comes to "worthwhile work well done" (thanks, Martha Berry and Berry College!)

I have thought a lot about this over the past week as I have struggled to set up a new system to help me complete and track a large stack of new applications for hospital privileges, a growing stack (we are already in fifteen hospitals and expect to be in sixty by the end of three years) that must be completed in a timely manner and in an exact way. Otherwise, like tax forms and other important documents, if you don't do them right the first time, somebody will notice and send them right back to you to do over again until you get it right. Some of the tips and tricks of the trade that I have learned from Peter Drucker, David Allen of Getting Things Done and Making It All Work fame and other gurus in the field have helped me tremendously. Some of them just get in my way and have to be modified to fit my own busy life and style. So what are the common denominators here? There are a few that are important to me, and I thought I'd share them with you. These have hit me right between the eyes this week, especially at two in the morning when I'm still copying the most recently completed application.

1) The hard work must have a real purpose. Seems like a no brainer, but you'd be surprised how many people slave away at a task that they think they must get done but that has a very ill-defined purpose if any at all. It's very simple really. If you know that the difficult task you are engaged in has a real purpose behind it, a real reason for why you must get it done, you'll focus on it and make it happen. if not, the frontal lobe will plod along for you and do the heavy lifting, but the older part of your brain will question how you survived this long with this quality of decision making skills.
Purpose drives productivity.

2) You must enjoy the process. If you set up your work space, whether at home or in your office or in your car if you travel a lot, you must have a space that is conducive to, as David Allen writes about, Getting Things Done. If you have to constantly get out of your chair to retrieve a stapler and walk across the room to use the copier and open up a closet and search for more paper, you waste valuable energy and chip away at the focus that is vital for completing your task. If you have a system in place that is fun to use, that shows you how efficient you're being in real time, you'll use that system and enjoy yourself while you're doing it. Before you know it, that mountain of bills is paid, that report is written, or the application is sealed in its fat envelope ready to mail. Love what you're doing in the moment, and you'll have so much energy that (like me last night at 2 AM) you'll lose track of time. Now, that's being "in the zone" for sure!
Enjoyment drives energy.

3) You must be effective as well as efficient. Even if you are enjoying things to the max as you whistle your way through a long to-do list in an ergonomically perfect environment that makes things flow effortlessly, efficiency will not automatically lead to effectiveness. This is where the rubber meets the road. This is what David Allen is talking about when he asks (forgive the paraphrasing), "How are you going to decide what you need to do at 3:20 PM tomorrow afternoon?" You have to use the energy and the excitement and your system and your work space to do things that matter.
I see this all the time in the mental health field, especially in these days of constantly monitored and measured productivity standards and oversight of busy professionals. The tendency is to schedule ourselves silly (I say ourselves because I am just as prone to this error as anyone else) and think that by virtue of a full calendar that we are productive and effective. As Mr. Allen describes, all it takes is for one associate to walk through your door with one crisis and your entire "productively" scheduled day is blown out of the water. So what are we to do?
Make sure, by constantly scanning our various landscapes (calls, emails, calendars, in basket, mail) that we are putting all this good energy and productivity to its maximum use. Focus on what matters. Focus on what really needs your time and attention. Let some things go. That's right! Don't do them! (Dump them, delegate them, whatever needs to happen) If you do this, at the end of the day you will feel appropriately tired, appropriately satisfied, and you will know that you have taken care of things that were the most in need of your time, energy, skills and creativity. You will have been not just efficient today, but effective. You will have made a difference in someone's life and in the larger world. Isn't that what we all really want? I like to think so.
Efficiency drives effectiveness.

So, what to take with you in your head about all this today and this week?

1) Purpose drives productivity.
2) Enjoyment drives energy.
3) Efficiency drives effectiveness.

I really hope that all of us can have a purposeful, enjoyable, and efficient week leading to maximum productivity, lots of positive energy, and the most effective impact on the world around us that we can muster.

We can do it!

PhotoAmbulation (or, Things Seen While Walking)

2009-10-04T21:45:00.002-04:00

ET, phone home?
Maybe you should just send a text instead...

What do patients really want?

2009-09-26T06:31:00.002-04:00

"He WILL see me right now! I don't care what else he has scheduled this morning. If he doesn't see me in the next thirty minutes, I WILL call the television station and make a really loud complaint and have them come down here and investigate the whole center!"

According to the receptionist, who was now quaking in the doorway of my cramped office on the back hallway, this irate mother had then pulled out her glitter encrusted cell phone, popped it open with the bright red, three-inch nail of her right index finger, tossed her jangly gold hoop earring out of the way, and held it menacingly to her ear.

"I know you're booked solid. Your ten o'clock is already out there and the ten thirty just walked in, but you have to see this lady." Her eyes pleaded silently.

Now in years past, when I was much younger, was fresh out of my residency, knew everything about everything and thought I understood the world completely, I would have told this frightened receptionist to go back out there and deliver this message: Dr. Smith does not negotiate with terrorists. I would have written the numbers for the local television station and the local newspaper down, added a couple of contact names just for kicks, and told the lady that that we could set up a conference call if she wanted to have me join in the discussion. I would have been brash, bold, and more than a little obnoxious. I might have gotten myself fired, and for good reason.

Now, after many years of seeing patients, listening to stories and getting a feel for what drives humans to do the things they do, I respond ( or at least try to!) these situations much differently.

"Tell her I'll be right with her," I say, smiling at the receptionist.

"Oh, thank you, thank, you, she'll be so glad..."

"No problem," I say, and shoo her back to the front to smooth the ruffled feathers of the mom on the war path. The long and short of it? She came back. We talked. We resolved the issue. No hard feelings. Mom left reasonably happy. Receptionist's pulse goes below one hundred. Now, what does this all mean? What do patients really want? Can I break this down for you?

Irate mother clicking red fingernails and threatening to call the television station = "I love my child. I'm scared about what I see her doing. You are a professional. I need your help. Now."

Paranoid patient threatening to hurt staff member or shoot someone = "The FBI is tailing me. Someone is trying to kill me. I'm afraid. I'm going to get them before they get me."

Severely depressed patient threatening suicide, but letting someone know of their plans to shoot themselves or overdose = "I am at my limit. I cannot go on like this. I want help. Please don't let me die."

The bottom line? The common thread?

People are people, even when they suffer from mental illness. They want someone to listen to them. They want to be heard. They want to be respected. They want someone to care.

All the high tech equipment, all the best protocols, and all the most expensive medication at our disposal are worth nothing at all if we don't make eye contact, stop talking, and start listening to what the person in front of us is telling us.

Pretty simple, you say?

Yeah.

Beautifully simple.

Baby Daddy

2009-09-25T06:51:00.003-04:00

baby daddy

March 10, 2006 Urban Word of the Day

Short for "Baby's Daddy". The father of your child, whom you did not marry, and with whom you are not currently involved.
That man isn't my boyfriend, he's my baby daddy.

OK, dear readers, an intense one for you this morning. I really need your help with this one. I'm struggling here.

I admitted five people to the crisis unit last night. At least two of them made mention of this urban phrase, "baby daddy". I know, I know, it's been around for awhile. It's not new. It's just that I have a terrible time wrapping my head around this one.

A man, not always but usually in this context a young single black male, has a sexual relationship with a young woman who may be as young as in her teens. This may be a one night stand, it may be a brief but intense flurry of carnal activity, or it may actually develop into what most of us would consider a relationship. The young woman is usually not using any birth control measures. The man most certainly is not. At any rate, the inevitable happens. The young woman gets pregnant.

Now, most of your know that my oldest daughter is pregnant, with a due date in November. This has been a joyous experience for us all already, with showers and buying nursery furniture and fantasizing about possible names and looking at ultrasound pictures and good-natured kidding about my daughter's ever increasing waist measurements. It's all been good. My son-in-law has been right in there with it, planning and getting a new apartment and putting together a crib and assembling a Pack and Play and all the things that one would expect an expectant father to do. He is, as my daughter has astutely pointed out, doing the male equivalent of nesting. Getting ready.

Not so for the baby daddy. As soon as the young woman gets the results of the home pregnancy test or goes to the doctor and finds that she is indeed pregnant, the baby daddy is gone. Out the gate. Down the road, In the street. He does not live with her. He does not look for a bigger apartment. He does not get a job. He does not buy or put together any furniture. He usually goes back to live with his mother. He hides, he shirks his responsibility. He is a coward.

He does not joyously anticipate the birth nine months later. He hides from it. He does not help to buy diapers or little clothes for the new baby. He avoids it. He does not go with the mother-to-be to her doctor's appointments. He shirks it. He is not there. He is not involved. He is a sperm donor, nothing more.

The mother is left to fend for herself, which in the population of people I see usually means going back to live with her mother and a houseful of other women and small children with nary a baby daddy to be seen anywhere. I have, quite seriously, talked with young women in the twenties who have already had three, four, five children or more, all with different fathers, not a single one of which has stepped forward to have any involvement at all with their offspring.

This is frustrating to me. Can you tell? How do we build a strong, vibrant society that involves all races, creeds, colors and ages if we cannot even start at the beginning with responsibility for the product of our own biological urges? Please tell me!

When my wife and I decided to have our very first child, the young woman who is now about to have out first grandchild, we knew that we were making a decision that would impact us for the rest of our lives. We chose to bring someone into the world that we would love, nurture, raise and support however we could, whatever it took, for as long as took. We would not run away. We would not hide. We would not shirk the awesome responsibility of bringing a child into the world. We would choose to be parents.

Though I know it is cliche, it is true, my dear friends and readers.

Any man can be a baby daddy. It takes a real man to be a father.

The View From the Other Chair

2009-09-24T00:24:00.002-04:00

I went out on the unit to find Ann tonight. She had just been admitted and I needed to get her history and do a brief physical exam to get her neatly tucked in for the night before I went home for some much-needed rest. One of the nurses helped me locate her. We found her wandering around the back hallway, dirty crumpled clothes in her hands, looking for the washing machine. She wore a faded hospital gown, a black knit cap pulled down over her face so that I could barely see her eyes, and large black boots with white athletic socks pulled up almost to her knees. Her eyes stared out blankly from behind thick round plastic glasses. She was mumbling inaudibly to herself.

"Ann, may I talk with you for a few minutes?" I asked, stopping directly in front of her to make sure she could see me.

Mumble mumble mumble.

"Ann?" the nurse tried to help me.

Mumble mumble mumble.

The nurse took her gently but firmly by the arm and began to walk toward the back of the unit where the physician's office was. I followed dutifully. We got to the door of the office and a strange thing happened. Ann walked in, turned around and sat down in my high-backed executive chair by the big desk. She crossed her legs, looked around the room a few times, then continued her conversation with herself and whatever voices she was obviously listening to. She leaned back toward the desk, much like I would have, and propped on her right elbow, much like I would have, and waited.

Well, what was I to? I crossed in front of her and took my seat in the hard student desk-like chair with the laminate topped arms that were used on blood drawing days. I squeezed into this uncomfortable little chair, and tried to make myself comfortable. The next fifteen minutes or so were not pleasant. Not only was the chair extremely inhospitable, but my patient was determined to say as little as possible to me in as few words as she could muster. It was like every young psychiatrist's nightmare board exam, when the "live patient" you draw never says a word and you are being tested on your interviewing and diagnostic skills. I tried several angles and leads and specific questions and open ended questions. Ann was having no part of it.

I learned very little tonight from Ann about what brought her to the crisis unit. I had to rely on the thick old green chart that the staff dragged out and the paperwork sent over by fax from the clinic.

I did learn, however, what it felt like to sit in the other chair, hard and unwelcoming, looking at someone who would not respond to me or give me any feedback at all. Someone who appeared to not know that I was in the room. Someone who was thinking about anything and everything but the person sitting in front of them during that interview.

It made me once again evaluate my own role when I am in the high-backed chair. Do I pay enough attention to what people are telling me? Does my mind wander, especially late at night when I'm tired and I'm thinking about the leftovers that are waiting for me at home? Do I show that I care?

Ann taught me something tonight, as my patients always do. You've heard the expression "walk a mile in my shoes"? In mental health work, there's always something new and interesting to see and learn when sitting for a time in the other chair.

Have you been in any situations lately that shook up the normal order of things and made you look at life from a different perspective?

Another baby?

2009-09-23T06:43:00.003-04:00

She came in to see me for follow up after an absence of a few months. We had originally been asked to evaluate her because of the incident, and she was now involved in marital counseling with her husband, who had his issues as well. Another story for another day.

She and her husband had argued and verbally sparred that afternoon, as usual for them, leading to one going to his room and locking the door and the other deciding to take off in the car for an impromptu trip to Wal Mart. They were young and had been married just a short time, just long enough to find the chinks in their spouse's armor but not long enough to know how to fight fair when a fight was really necessary. That afternoon, she took the infant with her, strapping the seven month old in the car seat in the back and roaring out of the driveway, gravel slinging out behind her Chevy. She got to the Wal Mart parking lot, still fuming and muttering under her breath, screeched into the first open space, got out of the car, and stomped purposefully past the cotton candy/boiled peanuts vendor and toward to entrance closest to the McDonald's. French fries would ease some of the hurt. Maybe a vanilla shake too.

Baby stayed behind in the car seat. The car remained unlocked.

A passerby, who just happened to work for social services (what are the odds?) walked past the car, saw the baby and froze. She tried the door-open. Looking around for anyone, and seeing no one, she opened the door, reached in and took the baby out, fumbling for her cell phone at the same time. She called 911. In the end, the baby was taken and placed into temporary custody with the mother's sister. The mother was charged with neglect of a child and was remanded for an evaluation with mental heath, with treatment to be rendered as necessary. Back to the session.

"How have thing been for you since I last saw you?" I asked.

"We're coming for counseling, both of us together," she answered vaguely.

"Any progress?" I queried.

"Yeah, I guess so. They say that if we finish up our sessions here we can get her back, maybe next month. We had another fight last week though. My husband kinda got, you know, arrested and had to go to jail for a couple of days," she finished lamely.

"What happened?"

"We were yelling at each other again, and his mom got in the middle of it trying to stop us. He sort of pushed her, I guess sort of hard, into the car. She called the police and they took him to jail. He got charged with simple assault and CDV."

"Will that affect your getting your daughter back?" I asked.

"Oh, I don't know. Maybe. I'm not sure if he'll be able to be at home with us if I can get her back or not. I told him, though, that I love him but I love her a lot more and if it comes to him or her, then he'll have to go and she'll be at home with me."

"Tough choice. Wow."

"Yeah, and it's harder to think about now that I'm pregnant."

"Excuse me?" I asked not able to adequately hide my surprise. "Pregnant again?"

"Yeah, a couple of months I think. I'm so excited. My second baby. I can't wait. I'm sure my daughter will be back home with me before this one is born. I'm sure."

"Well, I hope so," I said, dumbstruck. "I sure hope so. I trust that you will be able to finish your treatment and everything can get back to normal for you and your family." I wasn't so sure that this was going to happen, and her next statement justified my unease.

"Yeah, we'll be OK. If my husband can stay out of jail. And if my drug screens stay clean. I haven't smoked crack in a couple of weeks now."

Stigma (shhhhh...)

2009-09-19T06:00:00.001-04:00

stigma |ˈstigmə|
noun ( pl. stigmas or esp. in sense 2 stigmata |stigˈmätə; ˈstigmətə|)
1 a mark of disgrace associated with a particular circumstance, quality, or person : the stigma of mental disorder | to be a nonreader carries a social stigma.
2 ( stigmata) (in Christian tradition) marks corresponding to those left on Jesus’ body by the Crucifixion, said to have been impressed by divine favor on the bodies of St. Francis of Assisi and others.
3 Medicine a visible sign or characteristic of a disease.
• a mark or spot on the skin.
4 Botany (in a flower) the part of a pistil that receives the pollen during pollination.
ORIGIN late 16th cent. (denoting a mark made by pricking or branding): via Latin from Greek stigma ‘a mark made by a pointed instrument, a dot’ ; related to stick 1 .

I have had several people talk to me about the stigma of having a mental disorder this past week. One middle-aged lady had finally become convinced that she did indeed have a bipolar disorder, an illness that is definitely treatable and that can be borne with grace and style while enjoying one's life to the fullest like everyone else.

"I wish I just had a brain tumor or lung cancer or something else that you could x-ray, diagnose, cut out, and be done with!" she exclaimed with passion born of suffering and embarrassment. "This is not like having a broken leg, you know. There is so much stigma out there..."

Another very ill young man with a psychotic illness as well as two masters degrees in computer related fields told me in the courtroom where he was being examined that "It's easy to see a broken arm or leg, but it's not so easy to see a broken brain."

Points well taken, both.

Seeing mental illness every day and watching how it impacts lives gives me a bird's eye view of how stigma plays into the provision of mental health care in the modern world. We expect, as definition #3 says above, that in medicine we should see some type of outwardly visible sign that tells us that this person in front of us has a diagnosed mental illness. There should be a biological sign hanging around his neck, or a scarlet letter on her forehead or something that tells us unequivocally that this person is ill and needs our compassion and our help.

Unfortunately, the first definition usually applies instead. We tend to label persons with mental illness and consider them defective or bad or flawed. In other words, the circumstance of their having a mental illness, often through absolutely no fault of their own, is morphed into the person's being of inferior quality, damaged goods, crazy, or criminally insane.

How sad that even in 2009 we struggle with just making it easy for those afflicted with mental illness to walk in and ask for help. How troubling that those in positions of power and influence ignore these most needy members of our society, relegating them to lives of poverty and sadness and isolation from others. How criminal, yes criminal, that we cut funding for programs that provide inpatient treatment for those who are potentially dangerous to themselves or others, medications that are life-saving but too costly for most to buy, and psychotherapy that builds positive therapeutic alliances and skills that are portable and lasting.

Stigma is everywhere.

Talk about it.

Expose it.

Do something about it.

Fight it.

I thank you, and my patients thank you.

The Importance of Teeth

2009-09-18T18:53:00.003-04:00

It struck me like a fist to the mouth the other day.

A vast number of my patients, actually a majority of them in some practice settings, are edentulous. The have a dentin deficiency. They suffer from enamel emptiness. They are missing molars. They are bereft of bicuspids. It's really very sad.

We have been talking so much lately about health care coverage for those without health insurance that we sometimes miss the forest for the trees. In worrying about those who cannot get treatment for their myocardial infarction, we forget that there are probably many more who cannot get caries care.

Does it matter? I argue that it does. Allow me.

When someone walks into my office for the first time, actually as they are walking down the hall before they even get there, I have been trained to observe them, watch them, and evaluate all that I can before they ever open their mouths. I see how they shake hands (if they do), how they walk (in front of me or behind me), their body language (closed or open), how they are dressed, and if they have an abundance of tattoos or piercings. It is truly amazing how much you can learn about a person by not looking at them, but by seeing them.

Once they get into the office, sit down and start talking to me, another thing becomes very obvious. Those who have fairly normal dentition, even if it's not perfect, open their mouths and speak up. They talk to me. If they're not too depressed, they smile. Sometimes I can even make them laugh! They have nice smiles. I use that fact sometimes when people are very down and depressed, because getting them to laugh and smile and open up, if just for a split second, is gratifying both to them and to me.

Good dentition leads to a nice smile leads to open communication leads to increased self esteem and confidence. Also, many of my patients do not eat well and lack of healthy teeth sometimes exacerbates that problem, leading to poor physical health and other problems as well.

Lack of teeth leads to no smile leads to embarrassment leads to decreased communication leads to decreased self esteem leads to...well, you get the idea.

Let's see if we can get some dental coverage in there as we debate this whole health care thing, shall we?

Remember this old tune as sung by Judy Garland and countless others, as recently as the celebration of the life of the King of Pop? I leave you with...Smile.

Smile though your heart is aching
Smile, even though it's breaking
When there are clouds, in the sky, you'll get by
If you smile, through your fear and sorrow
Smile, and there'll be tomorrow
You'll see the sun come shining through
If you'll....
Light up your face with gladness
Hide every trace of sadness
Although a tear, may be ever so near,
That's the time, you must keep on trying
Smile, what's the use of crying?
You'll find that life is still worthwhile,
If you'll just....
Light up your face with gladness
Hide every trace of sadness
Although a tear, may be ever so near,
That's the time, you must keep on trying
Smile, what's the use of crying?
You'll find that life is still worthwhile,
If you'll just....
Smile

Suicide Sextet: Part Six: No Loose Ends

2009-09-14T21:41:00.005-04:00

I am told that he was very meticulous about the whole affair, and from what I knew of him that was most likely true. He had always been a quiet, unassuming man who was quick to volunteer his services wherever they were needed. He always wore a hat of some kind, odd in our warm climate even in winter, and a ready, genuine smile below an unpretentious moustache. He never appeared ruffled or upset or angry or frustrated about anything. He planned things and made sure that things were done correctly the first time.

His suicide was no exception.

He bought a gun a few months before the date he planned to use it on himself. He spent a little time scouting out the appropriate site for his death. It needed to be someplace that was remote and protected enough that he could get there undetected and complete his plan, but accessible enough so that someone could find him before too much time had passed. He did not want his family to be faced with his death and his decomposing body at the same time. One shock would be plenty. He plotted the site on a printed map that was found in his car after his death, along with the legally purchased gun. The scene easily told of the preparations that had been made to make sure his final exit happened the way it should, with little room for error.

At home, other clues to the preparation were obvious after the fact. As this was very close to the first of the month, he had paid all of the family's bills, neatly updating the spreadsheets where he kept the records of the household expenses. Electronically paid bills had been processed and dated for delivery. Bills that had to be mailed were on the corner of the desk in a neat stack of stamped, self addressed envelopes, ready for the postman. To leave nothing to chance, he had left the spreadsheets and other documentation open on the laptop, just to make it easier to find. Further guaranteeing success, he had made copies of everything on a small USB drive, carefully labeled and left in plain sight by the stack of bills. His family would be able to pick right up where he left off and pay next month's bills without even thinking about it-or him.

He left a grieving widow who just could not fathom his reasons for this final act of desperation. Was it selfishness, extreme anxiety, debilitating depression, anger, a secret drug habit, an addiction to pornography? None of these was evident. Even in the note, the last communication, he was all business. A stiff goodbye, a plan, and a wish that they might carry on. It would be better this way. For who?

He left a child, ready to leave home for college. What did he think she would do with this? How would she ever deal with his being stripped from her, forcefully and against her will? How would things be better for her without a father?

He had planned it all from the first.

Method. Site. Note. Bills. Records. Will.

He wanted to leave no loose ends, but he did not account for one thing.

For the family of a person who commits suicide, there is no end.

No end to the what ifs and whys.

No end to the sadness, the anger, the constant stream of tears inside.

No end to the life that he tried to snuff out just for himself, just to end his own interminable suffering.

At least in their minds, hearts and souls, he will always go on.

They will always go on.

Patient Insights

2009-09-13T22:54:00.001-04:00

"It's easy to see a broken arm or broken leg. It's not so easy to see a broken brain."

Suicide Sextet: Part Five: Survivor Guilt

2009-09-13T21:38:00.003-04:00

"I just can't get it out of my head. I keep thinking about it, what I should have said, what I could have done. I just can't stop it. It won't leave my head."

She sat across from me, a petite woman in her middle forties, dressed in casual clothing that matched her reported interest in horses and the outdoors. She sat at an odd angle to me, not facing me but more facing the window to her left, looking out toward the parking lot, away from direct eye contact. She was ringing her already reddened hands, rubbing them together, alternately pulling a wrinkled handkerchief back and forth through one hand and then the other. She was re-telling the story that I had already heard once.

"We had been fighting for a while. We had even separated, but we just got back together. I couldn't take his drinking. I couldn't take the drama, you know? " she asked, still not looking at me. "He called me back home to talk to him. He wanted to start over. I told him I just didn't know..." she trailed off. "He came out to the house, waited for me upstairs. I came up and he started yelling, screaming, not making sense. I told him that he needed help, but he thought it was me. It was always me. He was never wrong."

I watched her intently, silently. She needed to tell the story, even as she had already told it to the counselor earlier that day. I let her talk.

"When I came in to the room I saw that he had already found my gun. It was a pistol that I kept in the cedar chest. I don't know how he remembered that it was in there. He found it, and he was holding it and then waving it around, putting it up to his head, and taunting me. I told him to stop, that he needed to put the gun away. I begged him to put the gun down or to give it to me, but he wouldn't listen."

Her face reddened and her eyes closed tightly. Tears squeezed out from each eye, spilling onto her shirt.

"He looked outside and saw the police cars coming up the road, just down from the driveway. He looked at me, and he knew I had called them. I looked away. 'I won't go to jail', he said."

"Please just put the gun down," I begged him. "I'll just go downstairs and tell them to leave, OK? I'll tell them to leave. They can come back later to check on us. I made a move towards the door and turned to look at him. He had already gone into the hallway and was heading down the hall to another room. I ran down the stairs to head off the cops. I was going to tell them that everything was OK and that they could leave."

"I got down there, all the way down the stairs and out on to the front porch. I heard the shot. I thought oh, no, no, please, no, don't do that. I'm going to tell them to go. I will. Please."

"What happened next?" I asked softly.

"The cops went upstairs with me when I told them what had happened. They wanted me to stay downstairs, but I had to go. I had to go." Big tears now, dropping onto her shirt and jeans. No effort to dry them or wipe them away. "Why did he do it? What could I have said? What could I have done? I keep replaying it over and over and over in my head. What could I have done?" she asked, gritting her teeth now, the jaw muscles tightening and visible as she talked. She seemed to be asking this question of herself, not of me. "I can't get it out of my head. I can't stop it."

We focused the rest of the time on safety nets, contacts, friends, her own personal safety and making sure that she did not want to follow him and harm herself.

She cried and obsessed and revisited and talked and questioned.

She questioned some more, and then more.

Sometimes we never find the answers.

9-11-01

2009-09-11T06:00:00.000-04:00

It was a Tuesday, of course, late summer/early fall in South Carolina. Bright blue sky, wonderful smells in the air, and just a hint of the changing season. Enough to make you wish for pumpkins and turkey and pan dressing and kicking piles of leaves and smelling smoke. Enough of all this to make you feel safe, free, and wonderful. Enough to make you proud to be an American.

I was working in the mental health center that Tuesday morning, doing what I have done every Tuesday morning for over ten years now. I was talking to people with psychiatric illnesses who had been hospitalized against their will for reasons of dangerousness or potential for self harm. In other words, my job that morning involved making sure that the most vulnerable among us were given a fair shake by the mental health system and the court system, and that if they had improved sufficiently, that they would be released from the hospital that day. How American, yes?

After the second interview or so, if memory serves, a staffer ran into the room and told us that the patients and hospital staff waiting their turns to see us in the adjoining room were all glued to the television. It seemed that a small plane had just had a terrible accident, crashing into one of the World Trade Center towers in New York City. How terrible and sad, we all thought vaguely, going on about our work for the next few minutes, not thinking more about it at least at that instant. Soon, that same staff member came back with astonishing news. It seemed that the plane that had hit one of the twin towers was a much larger plane, maybe even a jet airliner. No, we all thought, at least to ourselves, how could that happen? Huge planes don't just lose control and crash into skyscrapers. It just doesn't happen.

The next few moments, really the next few hours, changed all of our lives forever. When we understood what was happening, as the first tower smoked and burned and helicopters began to buzz as did television commentators, we stood riveted to the floor, all of us standing up, restless and vaguely afraid but not knowing what we were afraid of, not knowing whether we should just go on about our days or wait to see if we were going to get new marching orders. The crash of the second plane into the second tower, with the graphic video footage that almost all Americans have seen by now, was surreal. We were being attacked. The United States was being attacked. I have always loved history, and I thought to myself, if there had been the real time coverage we have now in 1941, this is what Americans would have felt like as Japanese planes bombed Pearl Harbor. Just like the Gulf War and other incidents in recent years, we were all witnessing history being made, terrible history that would affect everything from how we traveled to how we looked at neighbors who didn't quite look like "us" any more.

I think we went through the rest of the morning in a fog. All of us wanted to make sure our families were safe. As crazy as it feels today, I believe that we all thought that attacks could happen anywhere the rest of that day, even in South Carolina. We made plans to attend church services that night, most of which had been cobbled together as prayer services for the victims as well as for the safety of all of us who remained in America that night, shocked, afraid and angry. My family did something else that a lot of other families did. We met for a meal of comfort food, hearkening back to that age-old tradition of gathering around a table and breaking bread together, offering solace and strength to each other.

One of the most symbolic things we did as the next few days and the real tragedy of it all became so apparent was to display American Flags everywhere. We put them on our cars, on our office doors, on our windshields. At our family home, we just happened to have a very large American flag that had been flown over the US Capitol at the request of our congressman. We had never displayed it. I found a few of the biggest, strongest nails I could find, attached them to the front of our house, and hung the flag proudly so that it covered most of the front porch and acted as an impromptu curtain and afternoon sun shade for the living room's French door windows. That huge flag stayed there, proudly displayed, for a very long time. It has long since been replaced by a smaller version that hangs from a more traditional mounting on a porch column, but there is rarely a day that Old Glory does not fly at our house.

Today, we remember that tragic day, 9-11-01, when so many innocent Americans died. We remember and honor a new crop of American heroes who rose to the occasion in service to their country. We remember when the American spirit, so often dampened of late, burned brightly at ground zero in New York City through dark days and even darker nights of digging, searching, rescuing, and recovering. We remember the fear, the anxiety, the terror, the anger and the relief when we knew that the worst of the initial attacks was over, though the aftermath was just beginning.

We remember. We honor. We grieve.

We are not fighting a war on terror. We are all struggling and fighting to regain a lost sense of humanity and brotherhood and common cause. We are fighting, or we should be, to be a global people who can live together and celebrate our differences as well as our commonalities. We are fighting not to be isolative and separate and exclusive, for if we do so, we shall all surely die one day, all of us the world over.

We are fighting to be a race that can live in peace.

Suicide Sextet: Part Four: The World is Ending

2009-09-10T00:02:00.003-04:00

She is twenty seven years old. The nurses have just told me that she is still psychotic and that they would like me to evaluate her for a change in her medications. I go out to the common area and she is waiting for me already, a thin, gaunt, waifish young woman, wrapped in a thin blue cotton blanket because the thermostat in the crisis unit is set on "meat locker".

"Hi. I'm Dr. Smith. Could we go back to the office so I can speak with you for a minute? Would that be all right?" I ask.

She looks at me and gives me a half-hearted smile, but says nothing. I extend my left hand, pointing the way to the office in the back corner of the common room, but she waits for me to go first, then follows at a respectful distance. We get to the small room and I invite her to take a seat in the hard plastic chair that sits to one side of the old gray metal desk. I sit in the heavy wooden chair across from her. She has still not said a word.

"The staff just told me that you're still having some trouble," I begin generically. "Can you tell me what's been happening today?"

"The world is ending soon," she says, then smiles in that odd way that psychotic patients do when the feelings inside don't match the facial expressions offered to the world around them.

"Is it?" I ask. "How do you know that?"

"The voices," she states matter-of-factly.

"You're hearing voices?" I ask, probing ever so gently.

"Yes." Concrete, to the point, no elaboration.

"What do they say exactly?" I ask.

"They tell me that the world is going to end soon, real soon." She looks to her left, where a long thin window reveals the gathering clouds of a thunderstorm in the distance.

"What else do they say?"

"They tell me to get ready. I have to be clean. I have to go back there (she gestures back out into the common area we had just come from) to the bathroom and wash and clean myself. I might not be clean enough when the world ends, so I have to wash myself."

"Do they tell you to do anything else?"

"They tell me I have to pray. I have to make sure that I don't forget anything that I'm supposed to pray for, in case the world ends."

"Do these voices sound like anybody you know?" I ask.

"One of them is my brother. That's the strongest one," she says.

"Your brother is deceased, right?" I ask. I had seen this in the record as I perused her history before talking to her.

"Yes." Her gaze dropped toward the floor.

"What does your bother tell you or say to you?" I ask.

"He tells me that I need to go with him, and that I will be OK."

"Go with him?"

"Yes."

"Is that why you tried to hurt yourself before coming here?"

"Yes."

What did your brother tell you to do?"

"Drink bleach."

"Did you do it?"

"Yes, I drank bleach. It didn't hurt me none. Next thing I knew, some dude from two houses down the street came and shoved me in his car, then I was at the hospital emergency room."

"How old was your brother when he died?" I ask.

"Twenty one."

"How did he die?"

"He was in jail. He hung himself."

"Oh, I am so sorry. That's terrible!"

"Yeah, he tells me all the time to come with him."

"Do you think that if we make some changes in your medications that we can make his voice go away?"

"Maybe."

Of course, we have to try.

"Doc?"

"Yes?"

"Do you think the world is ending?" she asks, making intense direct eye contact for the first time.

"Not quite yet, at least not for you and me I hope. When it's time, I'm ready, but I hope it's not for a little while yet. How 'bout you?" I ask.

"No, maybe not yet," she agrees. "Can I take that extra medicine tonight?"

"Of course you can. I hope it helps you have a good night's sleep," I answer.

"Me too. Thanks for talking to me, Doc."

"You're welcome," I answer.

She gets up, wraps herself in the blue blanket, and wanders out toward the bathroom on her right, but veers off to the left, towards her room, at the last minute.