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Shrink Rap

Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.

Updated: 2018-04-21T05:44:33.621-04:00


That Way Madness Lies


allowfullscreen="" frameborder="0" height="360" mozallowfullscreen="" src="" webkitallowfullscreen="" width="640">I thought this would be of interest to our readers! “THAT WAY MADNESS LIES…”  To be screened at the Richmond International Film and Music Festival  BowTie Criterion1331 N BoulevardRichmond, VA 23230Saturday, April 28. 2018 at 11:45 amTickets available at: with filmmaker Sandra Luckow New York, New York April 15, 2018 – THAT WAY MADNESS LIES…, an award-winning feature length documentary (Best Feature Documentary at the Hot Springs International Women’s Film Festival)  about severe mental illness and its effects on a family, their struggles with the mental health system and the law enforcement system, will be shown on Saturdayy, April 28, at 11:45am, to be followed by a Q&A with filmmaker and Yale School of Art faculty Sandra Luckow. There it will receive a special Jury Award.   First responders in law enforcement and crisis management, mental health advocates and families dealing with a mental health crisis are especially encouraged and welcome to attend. “Most honest portrayal of how severe mental illness ravages families and lives that I’ve seen!” - Pete Earley, author of CRAZY: A Father's Search Through America's Mental Health Madness. Film synopsis: One woman and her family trek the broken mental health system in an effort to save her brother as he descends into madness. Beginning as a testimony of his sanity, his iPhone diary ultimately becomes an unfiltered look at the mind of an untreated schizophrenic. Duanne Luckow, 46, began a scary, dangerous and ever-escalating cycle of arrests, incarcerations and mental institutional stays. Three months into his first court-ordered 180-day commitment at Oregon State Hospital, Sandra Luckow, his sister and filmmaker, visited him. He gave her his iPhone with 250 video clips. He wanted his experience documented. With their cameras, they expose an ineffectual and inhuman system as well as delve deep into the strength of family ties. Yale School of Medicine and the Global Mental Health Program at Columbia University say the iPhone footage Duanne shot as he descended into madness offers a rare, unprecedented, unfiltered look at the mind of an untreated schizophrenic. This is a specific harrowing story about a singular family trying to find its way through society's imperfections, stigmas and prejudice when dealing with mental illness. It is a search for answers - a free-fall into a quagmire of conflicting interests, policies, and despair. “The title of the film, THAT WAY MADNESS LIES…is a quote from Shakespeare’s King Lear, Act III, Scene IV. It speaks to the complications of dealing with mental illness, and our own uncertainties as to which direction we should pursue towards wellness and peace. “It is my greatest hope that this film will be an agent for changing the way we deal with our mental health in America,” says director Luckow. “This is the only film that I know of that has risen to the task of representing the terrors and tragedies of psychosis accurately and with immediacy and therefore the only one I know of that can truly serve educational and advocacy functions in changing the mental health system to one that promotes recovery and community inclusion as opposed to chronicity and dependency.” – said Larry Davidson, Ph.D. Professor of Psychiatry, Yale School of Medicine, one of the many psychiatric professionals around the United States who have called this film an important and accurate depiction of mental illness — one that should be seen by policy makers and those who care about the care and treatment of people living with mental illness in America.For further information about the film please visit the film’s website at ----- Listen to our[...]

Antidepressant "Withdrawal": Why Aren't Psychiatrists Seeing this "Common" Problem?


Over on The New York Times website, there is an article titled, "Many People Taking Antidepressants Discover They Cannot Quit. "  Benedict Carey and Robert Gebeloff write about how long-term use of antidepressants is increasing, and some people have difficulties coming off the medications with symptoms that constitute a discontinuation syndrome.  I'll let you read the article rather than quote it, because there was a lot wrong with the piece. It doesn't feel like a new idea that there are people who have protracted and miserable discontinuation syndromes--distinct from a recurrence of symptoms-- after stopping antidepressants. People have been writing in to Shrink Rap about these difficulties for the past decade, there are online forums around it, and The New York Times Magazine did a cover story by a man who stopped his Effexor and went through a difficult time with discontinuation symptoms back in 2007.   I don't think any psychiatrists were surprised to read that SSRI's have a discontinuation syndrome, and because of the symptoms that can develop, we routinely advise people to come off SSRIs and SNRIs slowly, especially from those medications that have a shorter-half life like Paxil and Effexor.  The question is not whether people might have symptoms, but about how difficult it is to manage these difficulties and how long they might last.  So while we have all seen people who have some discomfort after stopping a short half-life SSRI or SNRI, we think of this as something we manage by slowing the taper, switching to Prozac with it's very long half-life, or waiting it out with the idea that symptoms will resolve in 1-3 weeks.  What's different in this article is the idea that this is common, that patients struggle with intolerable symptoms even when they undergo a very slow taper, and that these symptoms can last for months or even years.   The article is one-sided in that it talks about the misery of the discontinuation syndrome with the overtone that "if only the doctor had told me that this would happen, I never would have taken the medication."  The article completely neglects the misery and dysfunction of the disorders that lead people to start these medications to begin with!  The article doesn't mention that one common reason for symptoms upon stopping --for example anxiety or sleep problems -- may be the recurrence of the initial problem that they medication was treating.  In some people, depression is an episodic issue and people can come off medications, with other people, depression, anxiety, obsessive compulsive disorder, premenstrual mood difficulties, and other problems these medications are used to treat are more chronic problems.  In these cases, stopping the medication may be like stopping insulin or synthroid: the problem is still there and staying on the medicine may make more sense.I think it's easy to be dismissive of the prolonged discontinuation syndrome-- to say that the symptoms simply don't last that long or cause that much misery, and if they do then the patient has obviously had a recurrence of their initial symptoms, something else is wrong, or it's all "in their head"--meaning we don't believe the person is actually having the symptoms they say they are having and they are a result of suggestibility or hysteria.   So what's good about this article is that it increases awareness of the issue and those people who are having difficult discontinuation problems may well feel a sense of validation in knowing that other people have the same constellation of symptoms.  I believe that there are patients who have these long and miserable discontinuation problems -- many have written into  the comment section of Shrink Rap over the years, and The New York Times found some to interview, including one psychiatrist who was having trouble coming off Cymbalta.   What I haven't figured out is this: Why haven't I ever seen any of these patients? It seem[...]

Stop Stigmatizing Psychiatric Treatment!


Stigma is a sticky, two-sided issue, one that we talk about often in our field of psychiatry.  Many things are stigmatized. While mental illness is an obvious one --and I'll come back to this-- many other things are stigmatized as well.  To name just a few: drug use, smoking, being a criminal, going to jail, behaving in a disruptive way, smelling badly and being physically unkempt in certain settings, begging for money in public, being on public assistance (in certain circles), beating your children (again, in certain circles), incest (in all cultures), being morbidly obese (especially when it happens in someone who makes poor food choices, as opposed to being the result of an illness), suicide, behaving badly after drinking alcohol,  sexually harassing your colleagues in certain circles, and I could go on and on.  Stigma, as you can tell by my short list, is a bit diffuse and subject to individual consideration, pertains to lots of troublesome behaviors, and depends almost wholly on the environment and consideration of others, and what is stigmatized  changes over time.  While stigma is troublesome in that it causes people to feel shame and self-loathing, it also has a role in society.  Stigma inspires some people to change  or avoid certain behaviors.  People certainly smoke less since it's become highly stigmatized and those who want to smoke at work are sent out into the cold to stand in little boxed off smoking areas.  There is a stigma to going to prison and being labeled a criminal and this is part of the deterrent to crime.  While suicide rates are rising, many people still don't end their lives for fear of stigmatizing their family, and as much as I see suicidal thoughts as a symptom of an illness, I do imagine that more people would choose to end their own lives if it left a legacy with no stigma whatsoever.  While it may have once been cool to be a "player," it's no longer okay to grope your co-workers.But what about mental illness?  Mental illness is not a behavior and it's not a choice, it's a constellation of uncomfortable psychic events, or symptoms, and sometimes having a mental illness leads people to behave in stigmatized ways.  But the illness itself?  Yes, it's mostly still stigmatized, despite our best efforts, but some conditions certainly more so than others.  We have not really clarified exactly what mental illness even is, but the reaction you'll get to saying you've had panic attacks in the past may be a bit different to the one you'll get if you announce that during manic episodes you run through the streets naked and max out your credit cards.  So I don't want to talk about the stigma of mental illness and substance abuse today,  I want to talk about the continued stigma of getting treatment for these issues.  Because one of the problems with stigma is that it discourages people from admitting to themselves or others that they have these problems and getting help, and so the treatment itself is stigmatized.This is the funny thing: most things that are stigmatized are unpleasant or have unpleasant consequences.  Jail is uncomfortable and leaves you with a bad mark.  Getting psychiatric treatment is not usually unpleasant, and it often leads to very GOOD things.  Being in therapy is stigmatized in many circles, but once over the hurdle, people ENJOY coming to therapy.  You talk to someone who cares about you about the difficult things in your life, you have a safe place to process what goes on in your head, and often just talking is a relief.  Most people like their therapists and look forward to sessions.  If things are not going well, the session is a place to process what's going on, to have someone who listens with concern, who may or may not offer helpful suggestions, who carries your history and story.  This can be a great relief and a tremendous comfort.  But people don't just come in when th[...]

A Plea For Smart Guns, The #MarchForOurLives Rally, and Talking with Dr. Weinstein About his Experiences With Involuntary Care


Yesterday, I was reading an article on how people make assumptions about animal motivation.  It is called  "Is This Dog Happy," and it reminded me of a post I wrote on Shrink Rap years ago called "What Max Wants," about the desires of our beloved late pet, Max.   I showed my daughter the old post from 2006, and as I was surfing around those early days of Shrink Rap, I remembered that I used to blog here a lot more.  In  2007, when all three of us were actively blogging, we had over 300 post.  Also, I realized  I used to be a lot more FUN.  Or at least I use to write about more light-hearted things.  Now I come to Shrink Rap when the world is bothering me, maybe once a month, and I have other venues for expression.  But I am also not as fun it seems, I often write blog posts about  more serious shrinky areas of distress.  Oh well, what can I say?  I am still fun sometimes in my real life, and the other day I made an emoji character of ClinkShrink.  I don't think she likes it, so I won't post it here, but I think it captures her.  That said, I now want to point you to the more serious stuff I have been been writing and thinking about lately.  For the first (and last) time ever, my original artwork is available to be seen in a national publication.  Over on Clinical Psychiatry News, I have an article talking about the very moving #MarchForOurLives rally I attended in Washington, D.C. on March 24th.  The speakers were all children and teenagers and they were amazing!  I wanted to add one thing to their requests for gun control: a plea for Smart Guns.  The artwork, as seen above, is the sign I made and carried.  As you may be able to tell, my artistic abilities arrested somewhere in late elementary school.  That said, please do read my article here: other piece I would like to direct you to is is also in Clinical Psychiatry News.  You may recall that I linked to an essay in the New England Journal of Medicine by Dr. Michael Weinstein about his experiences with involuntary psychiatric treatment and his successful journey to recovery from a severe episode of major depression.  Please do first read his article, Out of the Straitjacket.  Dr. Weinstein's essay caught my interest, because in researching Committed, I did not find that most people who were involuntarily treated felt gratitude--especially if they were physically restrained--even if they did get well.  I called Dr. Weinstein and he agreed to speak with me specifically about his experience with involuntary psychiatric care.  Please do read about our discussion at HERE:  ----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.[...]

On Forcing Street People to Get Psychiatric Treatment


In the New York Times, Benjamin Weiser has a beautiful and moving story about Nakesha Williams, a lovely and vibrant woman who graduated from Williams College and then became ill with a psychotic disorder. She lived for years on the street in New York City.  Please do surf over to Mr. Weiser's story, "A 'Bright Light' Dimmed in the Shadows of Homelessness." The story is a tragic one about a promising woman whose future, and ultimately her life, are lost to mental illness.  Despite so many people who loved and cared about her, and so many who tried to get her help, Ms. Williams dies alone on the street. She is young, and she dies of a treatable disease, a pulmonary embolism.  Mr. Weiser does a commendable job of re-creating her story and tracking down the people who knew her in the years before and during her psychiatric decline.  To his credit, he just tells the story;  he doesn't turn it into a plea for laws that make it easier to involuntarily treat people, and he doesn't go on about how this was a life that could have been so much different if only she had been forced to have psychiatric care.  I found the story to be a richer one told simply as it was without the moralizing.So having said that, I am now going to invoke my role as an expert on involuntary treatment to talk about the plight of the "homeless mentally ill."  Why the quotation marks?  Well, first I'd like to differentiate those who are homeless from those I prefer to call 'street people.'  You are homeless if you are an adult without a stable residence, and most people who are homeless are not sleeping on the streets.  They may be in shelters, in motels or the single room occupancies, or staying in the guestroom or on the couch of a friend or relative.  Those who are actually sleeping on the streets are our society's sickest and most disenfranchised members.  The quotations also serve to remind me that "the mentally ill" is not a term I like to use: these are people with psychiatric disorders, not to be defined by those disorders.  While many like to talk about the plight of the homeless mentally ill, I'd like to suggest that as a society, we should invest our resources in helping all of our countrymen who sleep on the streets, whether they are mentally ill, addicted, or simply indigent.  In a wealthy country such as we are, the fact that there are people who spend their nights on the street should be a source of shame to all of us.  Logically, this can't be about money: there is nothing cheap about leaving people on the street-- to start with, they have high medical expenses, and high incarceration rates.  One way or another, they cost us all money.  Personally, I don't believe it should be legal to sleep in public places, and as a society, we should feel obligated to provide sick and destitute people with  more than a nighttime cot in a room with other people where they may not be safe.  If you've followed my Shrink Rap posts, or read our book, Committed: The Battle Over Involuntary Psychiatric Care, then you know that the issues of involuntary treatment are nuanced and complex, and that I think it should be avoided when possible as there is the risk that involuntary care leaves some people feeling  traumatized and angry, and because we all cherish the right to make our own medical decisions.  You also may know that I'm not much for invoking "anosognosia" as a reason to force people to have treatment, and do see my post on this over on Psychology Today.  But you may also know that I believe there are times when there really seems to be no choice but to force treatment, and when it is simply the right thing to do to keep everyone safe.  A traumatized patient is better than a dead patient.  So what about Nakesha Williams, and others like her who are "dying with their rights on."  I messaged Mr. Weiser, th[...]

What's Caught My Attention Lately....


It's been just about a month since I last posted here, and what a month it's been.  I was away for a couple of weeks on a wonderful family vacation to Vietnam and Cambodia.  While it was a mostly psychiatry-free trip, the sign above did grab my attention.  It was a sign at the ecolodge where we were staying in Mai Chau, a rural area of Vietnam where water buffalo are still used as work animals in the rice paddies.  Why are persons with mental illness not permitted in the pool?  I have no idea, but it seems that stigma is rampant everywhere.  So do let me give links to the things I've been writing and thinking about.  ~When I last posted on Shrink Rap, it was in response to Pete Earley's mention of 'the worried well.'  Pete also ran my response   and John Snook of the  Treatment Advocacy Center wrote Pete a separate letter which he put up as it's own post.  By all means, do join in the fuss over on Pete's Facebook page where he entertains comments. ~I moved venues and put up a somewhat related post on PsychologyToday called The Perplexing Semantics of Anosognosia: Why An Obvious Phenomena Has Sparked Controvery.   See what you think, and I look forward to your comments.  ~Over on Clinical Psychiatry News, I've written two articles on everyone's favorite topic: Medication Prices.  In the first article, I did some comparison shopping for Abilify (aripiprazole) and Provigil (modafanil) and found that the prices varied by HUNDREDS of DOLLARS (and yes, I did mean to yell) per month, depending on the drug store.   In the Second article, I interviewed co-founder Doug Hirsch and learned about how drug prices are set and why GoodRx is able to offer deep discounts.  Finally, I'd like to send you over to today's New England Journal of Medicine to read a powerful article about a surgeon who was involuntarily treated for a suicidal major depression.   ----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.[...]

Insurers, Not Legislators, are the Gatekeepers to Care, and a Call to Deep Six the Term "Worried Well."


Over on Pete Earley's blog, there is a post titled: Senators’ Letter To SAMHSA Is Misguided: Dr. McCance-Katz Is Doing What Congress Demanded Pete is on the Interdepartmental Serious Mental Illness Coordinating Committee,  a group operating under the Department of Health and Human Services. He is an extraordinary writer and a tremendous mental health advocate.  His post inspired me to rant at him (Me rant?  Shocking, I know...) and Pete and I are both posting my response.  I can't begin to capture the essence of his post on the controversy over the NREPP website, nor will you need to understand that to read my response, but  please read about it at the link above.   ____Dear Pete:Thank you for your latest blog post on the work Dr. McCance-Katz is doing and thank you, again, for serving on the ISMICC.  Let me start by saying that after 25+ years as a psychiatrist, I've never heard of the NREPP website, so I'm not certain whether it's it is a good thing or a bad thing that the website is now down.  Instead, I'd like to respond to some of the things that were said in the course of your blog post.You used the term "worried well."  Please don't use that term, ever.  It implies that there are people with legitimate suffering because they have "real" mental illnesses, and those whose suffering is trivial because they don't have "serious" mental illness.  Suffering is suffering-- it all hurts, and sometimes those with no obvious signs of mental illness surprise us all when something suddenly goes horribly wrong. Psychiatric care is expensive, poorly reimbursed, time consuming, and stigmatized; people don't present for treatment for trivial reasons. There is the implication that some people are more deserving of care in a way we would never dream of bifurcating in any other field.  Could you imagine if you went to the ER with chest pain and were derided because it turned out you had heartburn or a pulled muscle and were not having a heart attack?  As doctors, we help people who are in distress, we don't make the distinction about whose suffering is valid and worthy of treatment.  I am all in favor of giving more resources to people with chronic and disabling mental illnesses -- these are society's most disenfranchised members, their suffering and the suffering of their families is immense, and they use our resources one way or another.  If not through appointments with psychiatrists and the cost of their medications, then through lost productivity, the cost for medical care incurred from unhealthy life styles, and the cost of institutionalization.  What I find difficult about these discussions is that psychiatry is the only arena where advocates ask for money for one set of patients at the expense of another.  We don't ever suggest that money to treat metastatic lung cancer should come from denying treatment to those with basal cell carcinomas.While I have you here, I'd like to bring up a related topic that perhaps you can get the ISMICC committee to look at, one that all of us might be able to agree on.  When the topic turns to serious mental illness, the loudest and most controversial agenda is about legislation to make it easier to involuntarily hospitalize patients.  While there are cases where this is an issue, for those of us in practice, there is a bigger issue: the real gatekeeper to getting very sick people adequate and optimal care is not the law, the gate keeper is the insurance/mangled care industry.  Insurers have a erected a barrier to inpatient treatment which has set the standard for admission as "imminent danger."  There are times when everyone can agree that a patient needs to be in the hospital: the patient, the family, the doctor, but if that patient does not present as being dangerous, it has [...]

One Doctor's Struggles With Depression, Addiction, and Recovery: Finding Hope in An Intolerant Profession


Psychiatric News is running a series on Physician Burnout, part of an initiative by APA President Dr. Anita Everett.  They asked me to write about medical licensing for the series, and in the course of writing the article, I spent a while talking to Dr. Luther Philaya, an Emergency Room doc who lost his license for his addiction to alcohol and opiates.  Dr. Philaya sought help and things did not go smoothly.  Instead of writing about licensing, I ended up writing about Luther, and I'll invite you to read, "System Changes Needed to Support Physician Seeking Help."  Dr. Philaya had more to say about the stigma of being a physician in recovery and wrote his own Op-ed piece for the Star Tribune.   Reprinted below, with his permission Recovery from addiction doesn't get the community support it needs It's no small achievement, but, surprisingly, it's greeted as an ongoing social stigma.  By Luther Paul Philaya January 8, 2018 In the fall of 2012, I entered treatment for addiction as a broken physician and man. Opioids were one of my drugs of choice, as they are for so many in today’s society. After weeks of intensive therapy, I was able to let go of the demons that had haunted me for decades, ones that I had medicated away with drugs and alcohol. More than 100 days later, I left the treatment facility with a renewed vigor for life — physically, mentally, emotionally and spiritually. I was eager to return to my medical practice with a completely different perspective, including a heightened sense of compassion and empathy for patients struggling with mental illness and addiction.I looked forward to being welcomed back at my place of work as well as in my community. As with a cancer patient enduring grueling treatment and receiving compassion and empathy from family, friends and co-workers, surely there would be those eager to help with my transition. Maybe a casserole or two would be waiting, or a few get-well cards. Without a doubt, my workplace would help with my reintegration back into practice.Sadly, I quickly realized that recovery from substance-use disorder is not celebrated by those outside of the recovery community. To the contrary, recovery — like active addiction — is stigmatized in our society. Rather than welcoming me back, I became a pariah among my co-workers of 22 years. Former friends were, for the most part, gone. What support there was came from the recovery community, but even there I fought shame. I learned to quickly — quietly and with furtive glances — enter and exit church basements or recovery clubs.“Anonymous” became my mantra. The guilt and shame I experienced while in active addiction were there to welcome me into the recovery world as well. I began meetings by proclaiming, “Hi, I’m Luther and I’m an addict. I’m powerless over my addiction.” I learned to fear that I was one small step away from relapse.Recov[...]

Oh For A Self-Correcting World


Good bye, 2017.  Personally, it was a good year.  Politically, not so much.  Our country has become so alarmingly polarized, and it seems we have so many problems!  Here in Baltimore, things are difficult for so many people: firearm deaths have surged, with 345 deaths this year -- a far higher number than New York City where there are under 300 deaths, even though New York has many times the population that Baltimore has.  Overdose death have surged as well. Crime, poverty, homelessness,--they are all big problems.  The latest tax cuts promise to help corporations, and perhaps they will be good for the overall economy, but I worry about the effect these legislative changes will have on access to health care, and on our country's most vulnerable people.  And even among the "haves," depression and anxiety is rampant, suicide rates are high, substance abuse disables and kills, and we talk about doctor burnout and suicide in a country with physician shortages.  It's all disheartening.I wish innovation were easier.  Our war on drugs has been a failure, and in moments of desperation, all sorts of things get tried.  Then sometimes, the 'solutions' become part of the problem.  For example, Physician Health Programs were an innovation to help struggling docs, and they have been very helpful for many, but there have been reports of abuses, and over on Clinical Psychiatry News, I wrote an article asking if PHPs were diagnosing for dollars.  Rehabs have popped up everywhere, but many of them are not using evidence-based treatments, and so much of treatment for opioid abuse still focuses around blaming the patient, moral failures, and an emphasis on abstinence-based treatments which are wonderful if they work for you and terrible if they leave you dead when a medication-based treatment might have given you some chance to live.  Given all the failures in our war on drugs, I might like to see how things transpire if we decriminalized all drugs of abuse, but somehow these things happen in sweeping moves, and if that doesn't work, it's hard to undo.  Medicine has adopted Electronic Medical Records as a standard.  They add hours to a doctors day, contribute to physician burnout, and don't clearly improve the quality of patient medical records or clinical care: in fact many patients don't like talking to doctors who are clicking away and not getting to know them as people.  Maybe it's still growing pains, and surely the databases they generate are helpful in research to learn about factors that effect disease and the efficacy of treatments.  Maybe we will grow into these records, but they were rolled out with incentives, or in hospitals where they cost hundreds of millions of dollars, so at this point, there is no going back.So I long for a world where we could try innovative changes -- in how we tax people, in how we address epidemics, in how we solve a multitude of problems, not by using the methods of the person who speaks (or tweets) the loudest, but by trial and error, with test runs on small segments of the population, with the ability to go back or try something new (easily) if what we try doesn't work.  Gun control, physician burnout, drug treatments, interventions for those who are name your problem.  Oh for a self-correcting world.   ----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.[...]

Recent Reads: Black Man in a White Coat and Vengeance


I just wanted to put up a quick note about two books I've read recently.

Black Man in a White Coat is a memoir written by Duke psychiatrist Damon Tweedy.    So what's it like to be a black med student and doctor, and not just anywhere, but at Duke.  Tweedy notes that he was accepted at other top medical schools, but that he went to Duke because the only way they could attract African American students was by giving large scholarships.  That gives you a hint as to what the environment was like.  So it's not surprising to read that Tweedy was standing with a classmate, purposefully dressed in a polo shirt and khaki's, only to have the professor walk into the lecture hall and ask if he was there to fix the lights.  Ugh.  So not specific to psychiatry, but a good read with important insights into how racial issues play out in medicine.  

Moving on to fiction, you may remember Pete Earley from Crazy: A Father's Search Through American's Mental Health Madness.  Pete is a mental health advocate, but at night, he steps into a phone booth (remember those?) and steps out dressed as a novelist.  Paired with Newt Gingrich, this fabulous novelist duo has now written 3 books in a series: Duplicity, Treason, and now Vengeance.    They follow Major Brooke Grant as she travels around the world chasing the Falcon, a dangerous terrorist who ultimately knocks off everyone Brooke loves (or almost).  Vengeance is by far the best of the three books, and I don't want to say too much, because it's a better read without the plot spoilers.     (image)

Happy Holidays from Shrink Rap: Free Kindle Novel Promotion!


Happy Holidays!At this time of year, I like to set up free downloads to two of my novels. You can get these books for free on your Kindle from Tuesday, November 28th through Saturday, December 2nd at no cost. Double Billing is the story of a woman whose life changes when she discovers she has an identical twin. It's a quick read with a little  psychiatry sprinkled in.  One reviewer said: The book was a page-turner because of elegant structure and pacing.  I really cared about the author’s take on things –because she is a psychiatrist? because I’ve followed  her blog for a while?– which meant that I was interested in the protagonist’s thoughts, feelings and actions.  At times I ached for the mess her life was in, at others I wanted to shake her into action, and then she’d find her backbone again, just in the nick.   Home Inspection is a story told through psychotherapy sessions in a format that is similar to the HBO series In Treatment. Dr. Julius Strand is a psychiatrist who plods along in his already-lived life until two of his patients inspire him through their own struggles to find meaning.  One reviewer wrote: I like to read all sorts of books, but books where there's something in it that reflects a part of me, a part of my life, a part of my experiences, are something I go out of my way to find. I have not found any fiction book that does nearly as much to show what psychotherapy is like.There is is a single link to my Amazon page with all my books here. If you don't own a Kindle reader, you can install a free Kindle app on your computer, tablet, or cell phone by going here and then you can read any Kindle book. You don't need to buy a Kindle to read on your computer, tablet, or smartphone.  Both novels are also available as as paperbacks from Amazon, but not for free.  And our two non-fiction books can also be found on that page, but again, not for free.I'm more than happy to have people download my novels at no cost -- I'll be keeping the doctor day gig -- so please tell/tweet/blog/share the free promotions to anyone you think might be interested. Finally, If you do read any of the books, please consider putting a review on Amazon.     ----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.[...]

Laura's Law (outpatient commitment): The Answer to Preventing Mass Murder?


2017 has broken the record for the most mass murders in a single year -- not something to be proud of, my fellow Americans.After the latest mass shooting in Tehama, California, John Snook, the executive director of the Treatment Advocacy Center had an op ed piece in the The Sacramento Bee titled "Tehama Country had a tool to Get the Shooter Into Treatment.  It Just Didn't Use it and the System Failed."  The article notes that Laura's Law, where a judge orders a patient to get outpatient treatment, exists in many California counties, but not the one where the shooter lived.  If only, if only.We know little about this shooter.  He was a violent man with a history of stabbing a woman (he was out on bail) and of shooting at neighbors.  His sister has stated that he had a long mental health and he was paranoid, and anti-government.  Prior to his shooting spree, he killed his wife and buried her in the floors.   The shooter worked as a marijuana farmer, we know nothing about his drug use or his treatment history.  He was known to the police, and clearly repeatedly dangerous, but the judicial system saw fit to let him remain out of jail on bail, which his mother in North Carolina posted, while he awaited trial. His guns were made by the shooter with pieces he had ordered and assembled, other guns were registered to someone else (?stolen).  He had a history of violence, and this crime does not sound to have been a surprise to the neighbors who feared him; one of the victims was the woman he had previously stabbed.So would this mass shooting have been prevented if Laura's Law was implemented in his country?First off, we don't know about the shooter's mental health history.  Oddly enough, while Tehama does not have outpatient commitment, the shooter could have been confined on an inpatient unit if a "5150" had been filed to detain him for an evaluation on an inpatient   Also, the shooter had multiple charges for violent crimes -- he could have been diverted to a mental health court and mandated into treatment through the legal system.  That also didn't happen-- or at least we haven't heard about any of those actions happening.  I suspect that the shooter fell through the mental health system  cracks, but it's clear he fell through the cracks in the legal system.  So would Laura's Law have prevented THIS mass shooting?  Perhaps, if the following list of stimpulations were met:~If the shooter's violence was a product of his mental illness.  People without mental illness are violent, and people with mental illness are violent for reasons unrelated to their psychiatric disorders.~If the shooter's symptoms that caused him to kill people were eliminated by the use of psychiatric medications.  Not everyone has a good response to medications and so far, we haven't heard that he was so much better when he took medications.   Forcing people to take medications doesn't fix/prevent everything, and the average length of stay in a forensic facility for people who have committed violent crimes due to their mental disorders is YEARS.  Sick, violent people don't magically get better with a judge's order.  ~If the perpetrator was ordered to treatment and if he complied with the order to go to treatment and to take medications.  Not everyone does, and from what we know, this man broke laws, both with his violent behaviors, and with his planned and purposeful assembly of illegal weapons.~If services were available for the perpetrator to receive them. In half the counties in this country, there are no mental health professionals.~Does Assisted Outpatient Treatment prevent gun violence?  We don't know.  In New York, where AO[...]

When Paranoia Meets Reality: Your Medicine Snitching On You


Medication non-compliance is a problem: patients don't take their pills.  We hear about it all the time in psychiatry: people don't take their medications and they relapse.  Sometimes they decide they don't need them when they do, sometimes they don't like the side effects or risks of the medications, but mostly, they just forget.  You may hear about this problem as if it belongs to psychiatry, but it doesn't.  Patients don't take their cardiac medications, either; in fact humans are only randomly compliant with all types of meds.Swoop in technology, here to solve the problem.  Now sensors placed in tablets can notify the doctor and up to four other people to inform them if and when a patient has taken their pill!  And what pill was was the first to be approved for the use?  Abilify: an anti-psychotic medication used to treat schizophrenia and bipolar disorder, and also used to augment anti-depressants.  Was that the wisest choice?  To have a tattle-tale system in a medication used to treat paranoia?  I'm thinking there could be a better place to start.So the patient swallows a medication and his stomach acid signals the sensor.  He also has to wear a skin patch on his abdomen, under his ribs.  A notice goes out to an App on his doctor's phone, and to anyone else he wants notified (presumably himself).  He has to consent to this, but questions have been raised about whether the courts will require patients to do this in terms of release from incarceration, for mental health courts, or if it will be priced in such a way to incentivize it's use.  Will people be coerced?  Will they like it?  Will they remember to check their App to see if their loved one took their medication?  Do doctors really want to be notified every time a patient takes their medications?  Will EMRs now have boxes to check to verify that the doctor has looked to see if the patient has swallowed his pill, as directed, daily, at the correct times? Will doctors be liable if they fail to check results and take action when patients aren't taking their medications and if there is a bad outcome? Will sensors work to improve medication adherence?  And then there is the Creepiness Factor.   You can tell I'm a bit skeptical of this, but that's not new.  ClinkShrink will happily tell you that I was wary of the Internet the first time I went surfing: too slow, it will never catch on.  I was wrong. Want to read more? Here's the New York Times article: First Digital Pill Approved to Worried About Biomedical Big Brother.Your thoughts? ----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.[...]

Let's Talk About Jails and Mental Health


Really, this is a post for ClinkShrink, but she's been busy with other things.  Do you miss her? Let me invite you to listen to Clink's interview on Tier Talk/Corrections One, where she was interviewed about Are Prisons Turning Into Mental Health Hospitals?  Yesterday, I heard Dominic Sisti talk at Sheppard Pratt Hospital about mental health and incarceration: Dr. Sisti is the director of the Scattergood program for the Applied Ethics of Behavioral Health Care at the University of Pennsylvania, where I was an undergraduate just a few (hmmm) years ago.  I tweeted the lecture, as best as I could, along with photos of some of the slides, so do check out the hodgepodge of venting that is my twitter feed.  I want to use this opportunity to talk a little about the highly publicized statistics that many many people in jails and prisons are suffering from mental illness.  Many believe that correctional facilities are the new psychiatric facilities.  Why is this?~Dr. Sisti and the Treatment Advocacy Center, and many others, will contend that part of the issue is that state hospitals have closed their beds without providing for adequate community services, so this represents a "transfer" of people from one institution to another. I will add: ~Many people have psychiatric problems -- per NAMI, 1 in 5 in any given year --so we certainly would expect some people in jails and prisons to have mental disorders.~Mental illness often co-occurs with substance abuse, and substance abuse is a crime in our country.~Mental illness causes people to be poor, and poor people are more likely to be in correctional facilities, because poverty may lead to crime (eg. stealing food), and poor people can't afford bail or expense defense attorneys so they may stay in jails longer than people with financial resources.~Our country has the world's highest incarceration rate, and we imprison people we are mad out, not just those we are afraid of.  There has to be a better option than imprisoning people for nuisance/non-violent crimes.  Many, many people go to jail for "violation of probation" when they can't meet the conditions set by judges -- for many of these folks, showing up is something they just don't seem to be able to negotiate.  For some, there is home monitoring, for others there is weekend jail, but there are many people in our jails where incarcerating them amounts to our society cutting off it's nose to spite it's face: a legal record makes it harder to find employment and the cycle of crime continues.~Incarceration rates have gone up with the "War on Drugs," minimum mandatory sentencing requirements, and an increase in drugs and guns in our society in the decades following the closure of state hospitals.   Sometimes people suffer from mental disorders, and the symptoms of their disorder directly leads them to commit crimes.  For example, a person who is delusional and believes someone is going to harm him, so he hurts that person in what he perceives to be an act of self-defense and has no appreciation that this is wrong.  Or maybe the logic isn't that clear, but the role of illness is, such as shooting a president to impress Jody Foster.Sometimes people have symptoms of mental illness that lead them to commit crimes, but with a less obvious link to their illness.  For example, people with depression are often very irritable, so someone who is unusually irritable may lose their temper and get into a fight that they would not have if they were not ill.As mentioned above, sometimes mental illness leads people to conditions that make them prone to certain crimes -- for example someone who is too sick and disorganized to main[...]

The Chronically Suicidal Patient and Stigma from Within the Mental Health System


There's an on-line psychiatrist discussion group where docs exchange information, ideas and resources.  As in all things on-line, it's sometime is invaluable, and it sometimes makes me shake my head.  Today, I was tagged in a post that discussed an article in Psychiatric Times called We Need to Talk About Stigma in the Mental Health System.  Louise Harvey writes about her hospitalizations in the UK.   Here is an excerpt so that you get the idea, and in the UK the term "sectioned" means involuntarily hospitalized.Quickly it became clear that I was considered to be a histrionic, attention-seeking young woman whose problems amounted to an individual moral failing, and a refusal to take responsibility. I was not alone. There were other young women my age and we were all subject to the same invalidating experiences which served only to exacerbate our distress. Our common presentation was self-destructive; we self-harmed and attempted to take our own lives, refusing to suffer silently once our despair had surfaced, the seasons of being able to keep our demons under lock and key well and truly over.The common refrains we would hear from mental health nurses and doctors went like this: ‘just take responsibility;’ ‘there’s nothing wrong with you;’ ‘you are bed-blocking’ (even though they had sectioned many of us, including myself, and it wasn’t in our power to free up any bed); ‘stop playing games;’ and the worst of all, ‘no one believes you.’Despite being considered a risk to myself, and lacking mental capacity, these judgements were accusations of mere misbehaviour and laden with mixed messages: ‘you are too ill to make your own decisions,’ and simultaneously, ‘you should stop being willfully disobedient.’ It must be noted that these comments were not levelled at the male patients on the ward, and were not reserved solely for younger patients.This kind of treatment followed me for years until a desperate attempt to take my own life by jumping from a bridge startled others into taking me seriously. I wasn’t meant to survive. I felt that I was a lost cause and that my inability to just snap out of the madness was a personal failing. I may not have died, but stigma within the system kills. It is far deadlier than any amount of stigma that one might face outside of the system because these are the professionals we are told to go to for help. Many of my friends who were treated as I was have since taken their own lives because their distress was not taken seriously.This was my response to the group of psychiatrists, based on my experience as a clinical outpatient psychiatrist and upon the research I did for our book, Committed.  Just so you know, within minutes, another psychiatrist called me out as being wrong, so take it for what it's worth.   And remember, these issues of how to manage chronically suicidal people are very difficult for everyone: the patient, the family, and even the psychiatrist. -----Thank you for tagging me. This is a wonderful article, it gives us an insight into the world of the patient. I think we've all been ingrained (as people, not psychiatrists--if those can be different) that if someone does something negative to get attention, then we should ignore it so as not to reinforce it, and people who get suicidal as a means of 'seeking attention' (a horrible thing...note sarcasm) are often dismissed, or punished-- and the inpatient unit here is often used for punishment. The label "borderline" turns into name calling/blaming, and not the acknowledgment of a personality gone awry and something that no one would ever want to have. Would you want [...]

My Friends in High Places on the HHS's Interdepartmental Serious Mental Illness Coordinating Committee


Move over, there's a new federal mental health committee in town.  The department of Health and Human Services has formed the Interdepartmental Serious Mental Illness Coordinating Committee.  My friends Pete Earley and Elyn Saks are both on the committee, and Pete has been blogging about the committee for a couple of weeks now-- the good, the bad, the ranting, and the missed opportunities after the first day of meetings last week.  You'll be pleased to know that I didn't miss the opportunity to put in one of my concerns: I emailed Pete and Elyn to tell them how pre-authorization for medications is having a negative impact on the practice of medicine, and psychiatry in particular.  Nothing new, but it's a topic that every medical organization has been fighting for years and nothing ever gets done, so I thought I would ask that it be brought up again.  My thanks to Pete for including my concern on one of his blog posts. When people talk about serious mental illness (SMI), I always have the same reaction: What is it?  From what I can tell,  one gets the designation with a diagnosis: schizophrenia or bipolar disorder or severe depression.  Apparently it's not about illness chronicity or impairment, or spending time in institutions, or whether an illness responds to treatment.  I'm always at a loss: as I've said before, our diagnoses are not precise, prognoses can be wrong, and people can be very sick at one point in time and very well at others.  So while 1 in 8 adults are on SSRI's, 1 in 5 suffer from an episode of mental illness during the course of a year, and half of us will have an episode of mental illness during the course of a lifetime, these people with serious mental illness are quite few: 4.5 million Americans.  I wish these people wore signs so we knew who they were and could divide the resources appropriately.  That said, the conversation about SMI often flows to the topic of involuntary treatment.  It goes along the lines of ...if only.  If only we could force sick people to get treatment then they wouldn't end up in jails and prisons.  If only we could force sick people to get treatment then they wouldn't be homeless, on the streets, committing violent crimes and mass murders.  If only.  If only it were that simple.  What gets missed is that addiction co-occurs with mental illness, and poverty confounds it all --so if only people were not raised in poverty, exposed to violence, and addicted to drugs and alcohol, then so many fewer people would be living on our streets, in our jails, and committing acts of violence.  If only.  There is another problem with this kind of thinking.  It divides us into those who are FOR and those who are AGAINST forced care.  It leaves out the key factors of Access to Treatment and Engagement.  Not everyone who needs care can get it: we have a psychiatrist shortage in this country.  And not everyone who says No to treatment will continue to say No, but if they do say No and the response is to have guards brutally tackle them and inject them with sedating medications, then there is a good chance that future efforts at engagement may be met with resistance.  Sometimes, it helps to meet people on their own level, to get to know them, to let them become comfortable and trusting, and then some of these people who initially said No may become agreeable to getting care.  The argument goes that those who refuse treatment have an inability to see they are sick, that this lack of insight it a symptom of the illness, and therefore it is a medical issue, not [...]

Inpatient Psychiatry: Not All Bad


I'm going to send you over to the Washington Post for an article that was published last week, written by Stanford psychiatry resident Dr. Nathanial Morris:  please check out 'Psych Wards' aren't what you think.  Morris makes the point that the inpatient psychiatry units is portrayed something out of a horror show,  when really it is a place of healing.  He writes:These are places where patients put their lives back together, picking up the pieces torn apart by such illnesses as depression, bipolar disorder and schizophrenia. Caregivers from doctors and nurses, to social workers and psychologists work to heal the sick, to guide patients out of the abyss. Families often reconcile with loved ones. Patients may find hope in one another, opening up in groups, sharing meals, discovering the comfort of shared experiences.Morris is right. People go in to hospitals in miserable states and they come out better.  They don't, however, necessarily appreciate the care they've received.  As we note in our book, Committed, some people come out feeling terribly traumatized.  If they feel better, they may attribute it to reasons other than the psychiatric treatment they received.  Perhaps they healed from time, or being away from their problems,  or the kindness of a nurse or their fellow patients.   Ah, yes, moments of healing.Morris points out that part of destigmatizing inpatient care involves acknowledging psychiatry's dark past.  Again, he's right.  What he doesn't say is that psychiatry continues to be dark in many ways related to inpatient care.  Psychiatry is not a money maker -- the resources are not always there for the luxury rooms and pleasant surroundings that might be found perhaps on the orthopedic floor.  And beds are reserved for the sickest of the sick: those who are both ill and dangerous.  We remain the only specialty where pre-authorization for inpatient care demands a life-threatening level of acuity-- if you're not suicidal, you go home.  It means the inpatient units are full very sick people and sometimes there are dangerous, patients may hurt each other or the staff or themselves; it's the sad reality.  And treatment is sometimes dictated by doing what needs to be done in an understaffed environment to keep people safe, even if it means the care is not what is ideal in the long run for the individual patient.  This is not to ruin such a lovely article because Dr. Morris is right (once again)-- psych units are full of tender moments, they are about healing, and they aren't about torture.  Often, they are about pressing the 're-set' button after the power has gone out. We're short on beds and negotiating the system is difficult.  It should be easy.  If more people could or would get the care they need, we'd have fewer suicides, less suffering, and fewer people in jails.  Morris goes on to say: Overcoming the stigma against psychiatric units won’t be easy. But I think it’s possible. Familiarizing the public with psychiatric care is a first step. Stereotypes against psychiatric units endure when these places remain unknown and out of sight. By opening up about the realities of mental-health treatment, providers and patients can address the pervading views of the “psych ward” as a place of torture and imprisonment. This kind of transparency can illuminate psychiatric care’s potential for healing rather than horror.Bravo! ----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail d[...]

Swiping for Therapists


Over in The New York Times, Melissa Miller has an article titled "How to Find the Right Therapist."Miller compares it to dating, and she makes the very valid point that good chemistry helps, it's really nice to like and respect your psychotherapist, and to feel a sense of rapport.  In psychotherapy, the talking is an integral part of the treatment and the relationship itself can be healing.  So it is important in therapy that the patient be comfortable confiding in the therapist, be open and honest, and feel safe saying things that can make one feel vulnerable.Miller compares it to dating, and talks about the pleasure of comparing wedding plans with her finally-found perfect therapist.  She then offers advise on how you, too, can find a good therapist.  Her advise is awful.  Really.  It's not that some of her points aren't valid, but she starts by giving a quick summary of what type of professional you should see:Determine the type of professional you need.If you’re suffering from ailments like panic attacks, depression, post-traumatic stress disorder or obsessive-compulsive disorder, look for a clinical psychologist or social worker rather than a psychiatrist, said Dr. David D. Burns, adjunct clinical professor emeritus at the department of psychiatry and behavioral sciences at Stanford University School of Medicine.If the issue is something more like bipolar disorder, major depressive disorder, sociopathy, borderline personality disorder or schizophrenia, it’s best to see a psychiatrist or a psychologist with considerable experience in that specialtyI don't know Dr. Burns, whom Miller quotes, but really?  Don't see a psychiatrist for panic attacks, depression, PTSD, or OCD?  But, hey, we apparently do a great job curing sociopathy!  I don't get the division, and I'd suggest that all of those conditions are well-treated by psychiatrists (which may or may not include medications in the treatment).   Miller advises readers to check therapist reviews on-line.  She doesn't point out that anyone can review anything and there is no way of knowing that good or bad reviews are not verified to be from patients and may be from best friends, ex-lovers, or even the therapist himself.  I'd go for personal recommendations from doctors or known patients myself. And Miller proudly touts that she ghosts her eating disorder counselor and 'broke up' with her therapist by text.  Hmmm.....Do some research, she suggests, and it seems reasonable to check to make sure the therapist has reasonable credentials and hasn't been sanctioned by a licensing board for something egregious.  A quick telephone discussion is also reasonable, but the author suggests asking the therapist what they like most about being a counselor.   Again, really?  Maybe stick to 'Do you have experience treating my problem.' I'm not sure it's best to start a relationship with a therapist by inquiring about their personal motives for going to work each day; much as I love my work, being asked what I like best about my work by a stranger looking for treatment might make me feel like a college student being asked that wonderful question of "where do you see yourself in 10 years."  She goes on to address issues of insurance participation and finances.  She suggests that if it's too expensive that the patient should switch the sessions to once a month (not necessarily a bad idea, but shouldn't the therapist be consulted?) or use Skype or email for sessions -- and why would Skype be cheaper?  And how would[...]

The Interesting Thing About Reviews of Committed.....


Hello!  It's been a month since the last Shrink Rap post, and it's now summer.  I love the long days and the slower pace.  There have been many times when I have read something and have thought, 'I want to write a blog post about that....' but then time gets the best of me and I end up tweeting it instead. I do believe my brain has reduced itself to 140 character thoughts.  Please do follow me on Twitter at you may know, ClinkShrink and I are the authors of Committed: The Battle Over Involuntary Psychiatric Care, released by Johns Hopkins University Press on November 1st.  The last few reviews of the book have reminded me how divisive the topic can be.  While all the reviewers have talked about the book as being readable and dressed in the stories of people, the reviewers themselves have opinions on the topic and let them be known.  Let me tell you more.In Committed, we talk about the anti-psychiatry groups, and we give a voice to those who feel psychotropic medications are ineffective, harmful, or even the cause of psychiatric symptoms.  Reviewers from these groups have invariable noted that, as psychiatrists, we go on to write about the different aspects of forced care with the supposition that psychiatric treatments work, and we don't do a comprehensive challenge of their efficacy.  These reviewers are right: our combined 50+ years of experience is that our treatments are helpful to many people, and we limited our perspective to that of involuntary care. We were not interested in writing a book that questions the efficacy of the treatments -- that's been done by others, and the idea that psychotropic medications don't help everyone or cause some people to have intolerable side effects, is something we discussed in our first book, Shrink Rap: Three Psychiatrists Explain Their Work.  On the Mad in America website, Dr. Sandra Steingard starts her review with: Dinah Miller and Annette Hanson are two of the three psychiatrists who blog at Shrink Rap. After I started blogging, I began to search out other blogging psychiatrists and I found them. They also have articles published in Clinical Psychiatry News. My impression is that they are decent, well-meaning, and thoughtful psychiatrists (not unlike most of the psychiatrists I know) who want to demystify our profession. Their writing is clear, straightforward, and accessible. Like me, they are all practicing psychiatrists and they deal with the pragmatic challenges we face in our daily work. They offer critical views but they overall seem proud of their profession and their careers. While I respect their work, in that area we seem to differ; they do not seem to be burdened by the professional existential angst that besets me.On one topic we agree — the subject of involuntary care is the most vexing, contentious, and troubling topic for psychiatry. To their great credit, they have directed an enormous amount of attention and effort to this subject in their latest book, Committed: The Battle Over Involuntary Psychiatric Care. I found it interesting that later in her review, Steingard talks about the concoction of medications that Eleanor (the patient against involuntary treatment) was placed on in the hospital -- she calls it a 'shocking cocktail" and talks about our 'unexamined confidence.'  Ah, Dr. Steingard wasn't there for our behind-the-scenes discussion, or for the article that came out of this particular discussion-- Questioning Psychiatry's Assumptions About Li[...]

NAMI: or It's All in the Words....


As I mentioned earlier, I've written a post over on PsychologyToday about how I believe the upcoming NAMI election and the question of whether NAMI will cover a 'big tent' or a 'small tent' -- a focus on severe mental illness versus all mental illness-- is about forced psychiatric care.One the candidates for office, DJ Jaffe, responded to my PsychologyToday post and said it's wrong, and I should change it. It's an opinion, not a statement of fact, so I'm hanging out with my first amendment right to free speech.  Mr. Jaffe included his whole campaign speech and you're welcome to check it out.  His contention is that in broadening the tent to include all, the SMI  (serious mental illness) agenda has been pushed out into the rain, not included, and goes point-by-point through why this is so.  I'm moving the discussion here because it's an easier venue for me to negotiate (PsychologyToday has a more difficult template and requires editorial approval).Just some thoughts: Mr. Jaffe writes:For example, in almost all their communications NAMI National has replaced the phrase “mental illness” with the phrase “mental health conditions” as if mental illness were a dirty phrase not to be uttered in polite company.  My feeling is that I'm a psychiatrist and I treat psychiatric conditions, just as a dermatologist treats dermatologist conditions, or one might see a nephrologist with a kidney condition.  Mental health conditions, mental illness, psychiatric disorder.  The truth is that we don't really have a definition for this: DSM-V has nearly 300 diagnosis, it's easy to get into a box if you want.  The SMI folks tend to focus on diagnosis as though it's absolute and accurate and each one has a uniform prognosis, specifically schizophrenia, bipolar disorder, and severe depression.  Diagnosis can be wrong, it can have a variety of prognoses, and other illnesses-- such as severe obsessive compulsive disorder, severe anxiety, and eating disorders --can be terribly disabling and can cause incredible psychic torment.  "Minor" problems such as adjustment disorder, can result in suicide.  My pet peeve is with calling psychiatric disorders "behavioral disorders."  Many of the people I treat are lovely human beings who behave just fine, thank you.Mr. Jaffe says that anosognosia is far more important than access to services in keeping people from getting care.  Clearly, Mr. Jaffe has not tried to get care using his public insurance at a clinic in Baltimore.  Finally, in terms of words, I'm told that it's objectionable to those who advocate for the SMI population to use the words Hope and Recovery.  Who could be against Hope?  Who wants to go see a psychiatrist to be told there is no hope, that they will never get better?   Of course people get better, why else would they come?  All better?  What does that mean?  Most people experience a decrease in symptoms.  Many find that therapy helps them to understand their issues and communicate in a more functional manner, which makes their lives go more smoothly.  (Oh, but much of SMI advocacy is about medications with little thought to therapy).  Many people come in looking horribly sick, tormented and suffering,  and then do get better:  they return to work or to school or to having meaningful relationships.  It often takes time; it's unfair to tell people that they won't get better and have a poor prognosis because we just don't know.  &n[...]

NAMI's Upcoming Elections: Is It All About Involuntary Psychiatric Care?


Ah, so first visit Pete Earley's blog.  His last two post talk about the upcoming elections for NAMI's Board of Directors.  Big Tents, Small Tents,  a letter from the President of the Board, he's got the issues outlined.

I throw in my two cents over on Psychology Today's website: This discussion of who NAMI should serve-- those with severe mental illnesses and their families, or those will all mental illnesses?--is really about forced psychiatric care. Read my thoughts HERE and I'd love to hear what you think.


Join Us At APA!


It's days away: the American Psychiatric Association's Annual Meeting will be in San Diego.  I'd like to tell you about the talks we'll be involved in and invite you to come listen and participate. Please do come say hello!--------------------To search for sessions by topic or presenter, go to this link: Session ID: 3019 Symposium Outpatient Commitment: A Tour of the Practices Across States Date: Tuesday, May 23 Time: 8:00 AM–11:00 AM Speakers: Chair: Dinah Miller (Maryland) Presenter: Ryan C. Bell, M.D., J.D. (New York State) Presenter: Kimberly W. Butler, L.C.S.W., M.S. (New York State) Presenter: Adam Nelson, M.D. (California) Presenter: Erin Klekot, M.D. (Ohio) Presenter: Mustafa Mufti, M.D. (Delaware) Discussant: Marvin S. Swartz, M.D. (North Carolina)                           ______________________________Session ID: 2284  Workshop Are You a Sitting Duck Online? What You Can (and Can’t or Shouldn’t) Do About—and Avoid in the First Place—Negative Reviews by PatientsDate: Tuesday, May 23Time: 1:30 PM–3:00 PM   Speakers: Chair: Robert Hsiung, M.D. Presenter: Paul S. Appelbaum, M.D. Presenter: Dinah Miller, M.D.                 _____________________Session ID: 3010 Symposium  The Battle Over Involuntary Psychiatric CareDate: Wednesday, May 24Time: 2:00 PM–5:00 PM   Speakers: Chair: Dinah Miller, M.D. Presenter: Roger Peele, M.D. (in favor) Presenter: Paul S. Appelbaum, M.D. (APA's views) Presenter: Elyn R. Saks, J.D. (Saks Institute for policy, law, and ethics) Presenter: Al Galves, Ph.D. (MindFreedom International) Discussant: Annette Hanson, M.D.For more information about this session, read HERE. --------------------------Measurement-Based Care: Using Multidimensional Assessments to Drive Improvements in Outcomes in Integrated Care Settings Rapid Fire Talks Focused on Behavioral Care  May 22, 2017  Room 27 1:30 PM - 1:50 PM Presenter: Steven R. Daviss, M.D. ----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.[...]

Negotiated Rates: What No One Talks About in Health Care Legislation


Last week, the House of Representatives passed legislation for the American Health Care Act, the first step in repealing the Affordable Care Act, or as some would call it, Trumpcare versus Obamacare.  The American Psychiatric Association and the American Medical Association (and many other medical societies) oppose the new legislation.  An enormous concern is that the new legislation won't require insurance companies to cover preexisting conditions, or require coverage for mental health treatment or prenatal/maternity care.  Over the coming years, the new legislation is predicted to leave 24 million more Americans without health insurance coverage.There are many criticisms of the ACA, one being that it forces people to pay for care for illnesses that they don't have and many will never get.  I'm not sure why no one talks about policies where people can opt out of having coverage for cancer. Cancer is a very expensive disease, and not everyone gets it.  If you believe you're at low risk, why should you have to foot the bill for someone's lung cancer any more than you should have to foot the bill for your neighbor's episode of depression?  Sarcasm aside, I wanted to talk about something that I don't see discussed anywhere.  One huge and accurate criticism of the ACA is that premiums are high and deductibles are high.  I'm not a fan, and it leaves people angry that they pay so much for health insurance and get so little out of it.  But there is something missing in this discussion: if a person has health insurance and they see a doctor, have a procedure, have a lab test done, or get a scan, then the cost to the patient is the cost that has been negotiated by the the health insurance company, and it's remarkably lower than the cost to that a person with no health insurance. The craziness of our current health care system is that the people who can most afford to pay for their care are the ones who pay the least.  So the high deductible may mean that a person pays for his own care, and only sees the benefit of being insured if there is a catastrophic illness, but it also means that while paying for that high-deductible care, out-of-pocket care non-catastrophic costs much less than the uninsured person pays.  It's a crazy system where the poor subsidize the rich -- if a hospital will much lower fees from an insured person, why not accept those same lower fees from someone who doesn't have insurance?   Does requiring people to purchase health insurance even out in the end?  Not for those who are healthy: it leaves the "well" subsidizing the "sick," which in my opinion is better than the "poor" subsidizing the "rich."  No answers here.  I don't believe that health insurance should be allowed to exclude those with pre-existing conditions: it dissuades people from getting care for fear of acquiring this label, and it provides a service that only the healthy or financially comfortable can afford.  It's not even clear to me what defines a pre-existing condition: 23% of women in their 40's take an SSRI, do they all have a preexisting condition?  If you told your doctor you were struggling with stress during a difficult time and she jotted "anxiety" on as a diagnosis once, does that mean you have a condition? For catastrophic conditions, the taxpayer ends up with the bill anyway: before the ACA, if your car crashed or you were diagnosed with cancer or [...]

Roy on the Pros and Cons of Medical Marijuana


Medical marijuana was legalized in Maryland two years ago, and this summer we will be getting our first dispensaries.  Psychiatrists are starting to ask what this means in terms of treating patients.  Roy did a great job summing up some of the research for our colleagues:Unfortunately, because of the many historical restrictions on research, there is increasing amounts of data available, yet few "facts" to go by ("fact" as in "a thing that is indisputably the case"). These data are often viewed from differing perspectives. Such as absolute vs relative risks. Harm reduction vs harm avoidance. Public health vs criminalization perspectives. Use vs abuse (eg, plenty people use alcohol without abuse it, getting drunk, rotting their liver... same with cannabis).That being said, the National Academy of Science and Medicine just put out in January a comprehensive (500 pages) report on the health risks of cannabis. I have attached the 3MB pdf file for our MPS readers' enjoyment. They found about 10,000 relevant abstracts to review (leaving out another 10,000 that did not meet their quality review). I was surprised there was that much out there. I'll boil it down to the Executive Summary level. Their major conclusion appears to be that, essentially, we need more research. Beyond that, they divided up additional findings based on the strength and quality of the research:Strongest evidence:There is conclusive or substantial evidence that cannabis or cannabinoids are effective:For the treatment of chronic pain in adults (cannabis) (4-1)As antiemetics in the treatment of chemotherapy-induced nausea and vomiting (oral cannabinoids) (4-3)For improving patient-reported multiple sclerosis spasticity symptoms (oral cannabinoids) (4-7a)Moderate evidence for:Improving short-term sleep outcomes in individuals with sleep disturbance associated with obstructive sleep apnea syndrome, fibromyalgia, chronic pain, and multiple sclerosis (cannabinoids, primarily nabiximols) (4-19)Limited evidence for: Increasing appetite and decreasing weight loss associated with HIV/AIDS (cannabis and oral cannabinoids) (4-4a)   Improving clinician-measured multiple sclerosis spasticity symptoms (oral cannabinoids) (4-7a)Improving symptoms of Tourette syndrome (THC capsules) (4-8) Improving anxiety symptoms, as assessed by a public speaking test, in individuals with social anxiety disorders (cannabidiol) (4-17) Improving symptoms of posttraumatic stress disorder (nabilone; a single, small fair-quality trial) (4-20)Limited evidence of a statistical association between cannabinoids and: Better outcomes (i.e., mortality, disability) after a traumatic brain injury or intracranial hemorrhage (4-15)The above is from the first page of about 10 pages of summary findings, including findings of both benefit and risk that are in the Exec Summary of the document. If still interested, turn to pages 13 to 22 to read the rest. And dive deeper if you are really interested. As for patient education, I think one could turn these 10 pages into maybe 2 pages of "here is what we know and here is what we don't know". Of course, where one draws the dividing line is arbitrary, but start with those things that have the strongest evidence, with benefits on the left and risks on the right.Then people make up their own mind, like anything else... a risk/benefit discussion. Would you risk liver failure [...]

Guest Poster Dr. Maher on Dealing with Changes in Psychiatry Through the Years (But Especially Now)


Obviously, psychiatry has changed over time. We've gone from a field where treatment was mostly psychotherapy-- I'll purposely omit insulin shock, leeches, and lobotomy-- to one of symptoms, prescriptions, and side effects, as though these things occur outside of the context of a person's life.  Ah, you've heard me rant before.  And like all of medicine, it's no longer just about treating patients, it's about checking the right boxes, coding what happened in the session by the minute, those damn CPT codes, and now about the technology and the hits your fees take if you won't e-prescribe, file PQRS (?huh) data, and practice the way the insurers want, if you choose to accept insurance or work for an agency that does.  With all that in mind, I saw this lovely and angsty post on Facebook, and asked the author to join Shrink Rap as a guest poster.  I was so pleased when Dr. Maher said yes.  Her guest post is below.------ I'll be 65 next month, I will have been in private practice for nearly 40 years, and I'm trying to decide where to go from here. If you have time, would you help me think through this difficult decision? I trained in a time and a place when psychiatric treatment, other than for the severe mental illnesses, was about psychoanalysis. Even if you didn't go on for analytic training (which I did, right after residency, at one of the most classical institutes in NYC), your primary goal was to search for and speak to the complex humanity of the other. My 4th year psychopharm course was optional. Yes, the classical model was flawed in significant ways, but over time I took what I needed from it, I owned it and I loved it. Then prozac arrived on the scene and I woke up in a different profession. No longer was it about meaning and humanity and insight into who you are, how you got to be that way, and the unconscious forces that led you to get in your own way. No longer was transference the mechanism of action. My field became about symptom constellations, drugs and/or skills to fix what was wrong with you. This perspective always felt wrong to me, but over time I came to integrate the parts that felt right with the work I was trained to do, and it worked pretty well. I have a very good practice, partially private pay and partially insurance based. Aside from Medicare (helpful when some of your patients have been with you for 30 years), the other insurance I accept is the one that the NYC Dept of Education uses. Many of my patients are teachers, so their psychopathology falls within a range that I'm comfortable treating. Once long ago, that insurance company called and asked me to take a patient off their hands. She was a paranoid, depressed, obsessional, suicidal, entitled, angry and litigious woman who fired every psychiatrist she saw, called the plan daily and threatened to sue everyone she spoke to. I told them I would only take her if I could see her 4 days/week indefinitely, no questions asked. They said yes, and she never bothered them again. They left me alone after that. I've seen some people weekly for years without being bothered. But times are changing, yet again. No one would remember me from that time. No one would bend the rules to allow a shrink with dynamic understanding to engage a patient like that. The billing, coding and documentation requirements, and the medical complexities, are becoming more [...]