Yet more on lying

If I had known that Medpundit would link to my post about patients lying to the doctor, I would have added more commentary. (Blogging is a lot easier when you're sure that no one is reading your blog!) What I should have added:

a. Malingering and factitious disorder were discussed in a previous post. (To keep it simple, I didn't use the word "factitious.")

b. WebMD polled its readers with no attempt to explore unconscious motivations. It's the psychiatrist's job to try to figure that out.

c. Doctors are extremely wary of being scammed for drugs (especially narcotics and tranquilizers.) I don't think I appreciated the extent to which patients distort their history to avoid feeling hassled by the doctor, or embarassed (or fired) by the doctor.

d. It's still the doctor's responsibility to listen for discrepancies and help patients feel comfortable sharing sensitive information. WebMD has some suggestions for asking questions in a non-judgmental way. Sometimes I have to say, "of course you don't have to tell me everything, but patients get much better care when we know certain things about them." Sometimes, they need reassurance that we won't abandon them or condemn them. Psychiatrists often have an uphill battle, collecting some types of info. Patients know that they can be locked up against their will for certain things.

e. The library just sent me some articles about physicians' truth-telling to patients. (Did you just have an awful vision of an office visit, with the patient and doctor both misleading each other? Me, too.) To be continued....

Campaign imagery, part two

I see that I have been more charitable than some who comment on Naomi Wolf's analysis of Kerry's archetypal aptitude. A letter on Sullivan's site states: "The critique you just posted by Naomi Wolf has to be the most idiotic thing I've read in months. Part of it is unreadable. Teresa is opening a 'symbolic breach in Kerry's archetypal armor?' Whatever. Just so long as Sir John metaphorically unleashes his iconic sword to slay the dragon of legend and lift the imagined curse from our allegorical Land, I suppose we'll all be okay. The rest is nonsense..."
I don't believe that gender imagery is nonsense, but I do wish that more care and thought (and evidence) could be put into the analysis. And I wonder what Wolf hopes to gain, by going to Big Media with this stuff. (See my post, "With friends like these...") Who thinks that a daily torrent of criticism and advice, played out in the media, will improve a candidate's image?

The archetypal girlie-man?

As if Kerry doesn't have enough troubles! Now comes the question: is Teresa Heinz Kerry the wrong icon, in the wrong campaign, at the wrong time? Is she contributing to a perception that her husband is less than macho? Naomi Wolf seems to think so. She says that Heinz Kerry is "emasculating" her husband in the campaign. This is accomplished by the particular way in which she shines the spotlight on herself, keeps her late husband's name, and projects an image that contrasts sharply with archetypally-appealing "Bush women."

Oh, where to begin? One might accept that archetypes are central, powerful elements of culture, but they haven't totally crowded out rational debate. How about a call for evidence: has Wolf surveyed American women, and examined their responses to the icons suggested by the campaign? How about a look at facts portrayed in the article: is Kerry relegated to the inner reaches of newspapers because he's archetypally emasculated, or because he has taken so long to develop a coherent message, and stopped talking to reporters for several weeks?

For me, the mystery of the duo's iconography is how a firecracker like Heinz Kerry ended up with the solemn, staid-appearing Kerry (who, at rallies, sometimes looks more like he is announcing his retirement, raher than campaigning for president). But this, to me, is fluff. The campaign's problems seem to go much deeper than gender imagery. I have at times wondered which side Heinz Kerry is on; Medpundit cited this article, describing Heinz Kerry asking her husband, in front of a reporter, if he should have therapy for "Vietnam nightmares". (Is that supposed to be an emasculating message too? It is a naive and potentially damaging message for a host of reasons, however well intentioned.) Ironically, in the same article, she is quoted as saying that politics is driven by the "immediacy of pictures." As for the spotlight, it gravitates towards Heinz Kerry, with her energy and fire. It's hard to know what she can do about that, other than excusing herself from the campaign. I'm pessimistic about archetypal engineering, and I think that attempts to manipulate one's image can backfire badly.

I think that Kerry has other archetypal challenges. Have you seen the comment to one of my posts, that calls Kerry "Lurch?" Wasn't "Lurch" the butler for the Addams family? How's that for an archetype?

(addendum: thanks to Andrew Sullivan for the link to Wolf's article.)

Caffeine 101

To all students returning to our campuses, and to anyone else who is thinking about increasing their caffeine intake, I offer this info about caffeine toxicity from DSM4. "Symptoms that can appear following the ingestion of as little as 100 mg of caffeine per day include restlessness, nervousness, excitement, insomnia, flushed face, diuresis, and gastrointestinal complaints."

What if you've been marinating in caffeine? "Symptoms that generally appear at levels of more than one gram per day include muscle twitching, rambling flow of thoughts and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, and psychomotor agitation."

So, how much caffeine are you ingesting? The Center for Science in the Public Interest has tables here and here listing approximate, "typical" caffeine content of some beverages. Tolerance develops with chronic use, but higher-than-usual caffeine intake can cause problems. (Thus, one of our first questions to anyone suffering from anxiety: how much caffeine is on board?)

Off meds by the holidays?

In our clinic, more patients are asking about stopping antidepressants. Some are well informed about the "discontinuation syndrome" that can make stopping certain meds difficult. (See Public Service Announcement.") I try to explore with them: why stop them, and why now? Is there a side effect that we should try to deal with? Has their mood improved, how long have they been stable, do they know that depression is often recurrent? How will we recognize if their depression is returning? For many patients, the advice will be: it's not a good idea to stop the med.

Have they been unhappy with the meds, or with seeing a psychiatrist in the first place? Have they accidentally missed some pills, and felt terrible? Some decide unilaterally, "I'm reducing these, I'm stopping these pills." A host of physical and emotional symptoms may ensue. The symptoms may signal that the depression is returning, or that withdrawal is occurring, or both. We try to sort it out. (Note! Note! I am only talking about certain antidepressants here! Not tranquilizers, not other drugs!)

How should most of these antidepressants be tapered? It should happen very slowly, and with monitoring by the doc. I tell them, "This never happens as fast as we'd like." But how many patients relapse, and are advised to resume the meds? The APA guidelines say: "Depression is, for many, a recurrent disorder. Among those suffering an episode of major depression, between 50% and 85% will go on to have at least one lifetime recurrence, usually within 2 or 3 years." Many patients choose to stay on the meds. For some, it's not an easy choice to make.

Brave new blog

University of Oregon students have returned to Eugene. They are having some sort of bacchanalia in the park behind my house. I'm sitting here wondering, how should a psychiatrist blog? Google doesn't seem to know. None of the search results are helpful. I'm trying to learn from colleagues' blogs. They comment on cases, and explain treatments, but they never give details or specific advice about treatments. They are completely confidential, with no inkling of patients' private information. (I haven't put my own name on my site, to add another layer of confidentialty, but some colleagues are braver.)
I'm paging through my reference books, with chapters like "Psychiatrists' Relationships With the General Public." Yikes - this one says that" the American Psychiatric Association once conducted a nationwide poll of its members to evaluate the mental health of a presidential candidate." It doesn't say which one. My own posts have tended toward urging people to restrain themselves from hurling diagnoses at candidates. That's almost my theme.
Anyway, there are comments about "being prepared for the public's reaction to psychiatry," - their fears, ambivalence, distrust, disbelief, stereotyping, and scorn. "Try not to be defensive," counsels the book in my lap.
There's a section about talking to reporters, and I'm wondering if that advice will help me. Blogging isn't like talking to the media; it's talking to anyone who wants to listen, every day, and dealing with some of the comments. But there are constraints on what I can say. "Keep the discussion general," it says. "Make it clear when you are just speaking for yourself, and when you are speaking generally for your profession." Have I been doing that? Excuse me while I scroll down for a bit, and check things out....

Check out Dr. Rangel's blog...

...for an account of a Scottish gentleman's struggle to have a 3 inch nail removed from his hand, navigating the national health system in Great Britain. It reminds me of my adventure with conjunctivitis in London, years ago. The hotel sent me to the Royal Eye Infirmary, a massive Victorian edifice, where I was given a number and directed to wait. And wait...
A stream of eye traumas hurtled to the front of the line. I learned not to ask, "how much longer?" After 12 hours, I was escorted to the slit lamp, and in less than 15 seconds, I had received a free eye exam, a free diagnosis, and free eye drops. (All for a non-citizen.) When the doctor found out that I was a med student, she called after me, "It's not too late to change your mind!" She had seen hundreds of eyes that day. She seemed chained to her equipment.
Are Americans prepared for that kind of care? Patients want more time with us, not less, and they want to see us sooner, not later. They already feel like they are on an assembly line. And do American doctors want to provide that kind of care? At least here in Eugene, doctors are feeling overburdened and undervalued. There is a potent comment following Dr. Rangel's post, about disparities in health care in America, and of course that is all true. But one would do well to think about the issues that Dr. Rangel raises....
Except for one thing. He says that in our system, increased work means increased rewards. But I know lots of doctors who are working harder, seeing more patients, but their income is declining....

Shoe's untied

"A lie can travel half way around the world while the truth is putting on its shoes." So said Mark Twain; but bloggers have turned this on its head. The exposure of document forgery has circled the globe at light speed, but CBS is still choosing its footwear for today. NYT reports that CBS might acknowledge doubts about its memos shortly. I like Andrew Sullivan's axiom: the more fervently one wishes that something were true, the more scrutiny and caution is needed. Yet, how to balance that with trust...the kind of trust that makes relationships possible, that makes society function? It's interesting that the White House has said that it did not question the documents, because it saw no value in questioning CBS. Likewise, it appears that the producer trusted the reporters. I work in a world where it doesn't matter if I was right yesterday. "I've been right for 20 years, so I'm correct today..."-- that attitude would get me booted out in a hurry.

Sadly, when someone is determined to scam us, and like Peter Pan, we want to believe....we will be taken in. Here is my all-time favorite forgery:
"Scholars will recall that several years ago a shepherd, wandering the Gulf of Aqaba, stumbled upon a cave containing several large clay jars and also two tickets to the ice show. Inside the jars were discovered six parchment scrolls with ancient incomprehensible writing which the shepherd, in his ignorance, sold to the museum for $750,000 apiece...
"Archeologists originally set the date of the scrolls at 4000 B.C., or just after the massacre of the Israelites by their benefactors. The writing is a mixture of Sumerian, Aramaic, and Babylonian and seems to have been done by either one man over a long period of time, or several men who shared the same suit. The authenticity of the scrolls is currently in great doubt, particularly since the word "Oldsmobile" appears several times in the text..." "Still (the excavationist noted that) this is the greatest archeological find in history with the exception of the recovery of his cuff links from a tomb in Jerusalem. " -from "The Scrolls" by Woody Allen, in "Without Feathers," 1972 (first appearing in the New Republic).

Slimefest

On call again...I'm missing the Eugene Celebration, our downtown festival, which looks to be a soggy affair, anyway (the rain has arrived). Last night, Eugene crowned its new "Slug Queen." The competition was fierce (the custom is that whosoever bribes best, wins). The winner has the requisite glitter, decadence, and funky charm (think glitzy, slug-costumed royalty, complete with ladies-in-waiting).

And what's this... a new twist this year. Slugs produce copious amounts of slime. So, unsurprisingly, the competition had a political slant. Aspiring queens lamented the slimefest on display in the presidential campaign...hardly any slime left for Eugene's "royals!"

There is slime in abundance this year. Mud-slinging ads, suspiciously-timed(and financed) books and movies, mystery memos. Slurs, venom, opprobrium...As long as the candidates can plausibly stand above the fray, the invective flows...

Who is swayed by all this? And who can keep track? I'm making a flow-chart of slime, outlining the attacks, counter-attacks, counter-counter-attacks and surprise smears. It will keep me busy until the debates, when I will once again have to face the issues. I'm being paged...I really am on call. Back to work.

Antidepressants and children, part three

Medpundit decries the chilling effect of the FDA's new warnings on prescribing antidepressants to children. In previous posts (see below), I've tried to clarify our approach to prescribing. It really hasn't changed all that much; caution and surveillance have always been advised.

What has changed is our perception of risk, and our approach to educating and working with the parents. One colleague e-mailed me: "I tell parents that their concerns (about the meds) are appropriate, and more studies are needed to confirm safety in kids. Nevertheless, I believe they are superior to anything we had previously. I always tell them they, the parents, have the ultimate authority over what is or is not prescribed."

Another says, "I have moved in my own view of the controversy from outright rejection of the concern...to a more considered stance. There really do seem to be small studies which show a correlation between antidepressant use in kids and S/I (suicidal ideation)....I still believe that depressed people, including kids, can have S/I... I tell parents that it seems unfair to withhold this potentially very helpful treatment from kids, and that large studies have shown that (antidepressants) help youth depression. I also say that it has always been, and continues to be, that depressed kids who are being trialled on treatment need careful monitoring."

But hear the other issue that Medpundit raises: she is not receiving timely help from her psychiatric colleagues. Her patients are in desperate staits, and there is intense pressure for her to do....something. Prescribe something, consult someone, refer somewhere. But how? We need more than caution and disclosure about med risks; we need to be more available to primary care docs on the front lines.

About "Comparing drug pricing"

Thanks to Dr. Bob, who cites a NYT article about a new federal website that offers guidance about drug prices and the new Medicare prescription drug benefit.
I tried to crunch some numbers on the site. A person in my zip code who takes Prozac 20 mg daily: no savings. A person taking Prozac, Seroquel, and Zantac: no savings with any of the drug cards in my area.
Who is helped by this program? I'm going to look at some other combinations of meds. I note that certain meds are excluded from the benefit (like non-prescription meds, benzodiazepines, and treatments for baldness, among others).
Looks like we will still rely on "patient assistance programs" and free samples for lots of our patients. We still haven't found a comprehensive solution to the crisis of med affordability.

A future shrinkette?

Scutmonkey offers a cartoon account of a med student's first experience with psychiatry. There is much truth in jest, as the saying goes; still, there are stereotypes and a lack of empathy here. I'm afraid that her impressions are shared by many others, and that some doctors will recognize their initial reactions to psychiatry in these drawings. It's clear, well before she informs us, that she won't choose to become a psychiatrist.

More on children and antidepressants

Dr. James Baker MD, at "Mental Notes," weighs in on the issue: "I can't tell you how many so-called "treatment failures" I've been asked to consult upon among teens on antidepressants for whom I could not discern why the patient was on the medication in the first place...." He thinks that some of these kids may be getting the wrong diagnosis, and hence, the wrong treatment, which contributes to poor outcomes. (Diagnosing children can be so challenging.....)

Surprise - while I'm posting this, Dr. Baker sent me a comment! (Thanks!) He's a firm advocate for using evidence-based treatments, which may include longer-term counselling and family therapy. He points out that "FDA officials say that none of the research they are using to condemn antidepressant use reaches statistical significance." Granted, there are tremendous problems with the research (ma'am, may we please enroll your desperately depressed child in a research study?)

I'll be interested to see how the FDA alters the official warnings. I'm reminded of a comment by Alisha, below: "I guess it's often easier to blame the pills..."

Re-living 9/11

Last night we listened to "On the Transmigration of Souls," by John Adams. Written for the victims of 9/11, it's a powerful work, for "orchestra, chorus, children's choir, and pre-recorded soundtrack," complete with street sounds, recitations of victims' names, and quotations from those pleading "missing-person" posters. I'm not a music critic, so this will be rough going, but I can say that it absolutely swept us off our feet, and back into the emotions of that time.

Adams has said that his goal was to create a "memory space" that captures the experience of loss and mourning. He hoped that it would speak to anyone who has experienced profound grief and loss....I think he has succeeded. The entire work lasts about 25 minutes (but, as in grieving, the recovery takes much longer). We have long been fans of John Adams, and he continues to inspire and move us.

Children and antidepressants

The parent on the phone is frightened. "What are these pills doing to my child? She says she wants to die."
I'm on call, covering for a colleague (there are no children in my practice). I've seen the news reports about the FDA warnings. Is her child more likely to die with the pills, or without? I try to figure out what else is upsetting the parent and child, and then I say something like this: that meds can affect behavior, that her child needs close monitoring, that her child should be assessed in ER.
Later, I debrief with some child psychiatrists. It turns out that different drug companies have had different definitions of "suicidal behavior," and it's been hard to sort out risks. And studies are sorely lacking. Some symptoms may increase impulsive behavior (I'm thinking of anxiety, panic, increased energy, and restlessness), and sometimes those symptoms are side effects of meds.

A depressed, impulsive, panicky patient may be at more risk of suicide. But untreated patients have increased risk of suicide. The take-home point: suicide is more likely in untreated patients. For most patients, the benefits of the meds outweigh the risks. But treated patients need really close surveillance.

Thank you, Medpundit....

Dr. Sydney Smith, MD, has linked to me today (and says such nice things)...thank you very much! Dr. Smith, a family practitioner, somehow finds time to blog about medical news and politics, while pursuing her profession (or "practicing her love," as Bush might say.) She has been an inspiration to me, so this is really an honor.

Scams and the scamming scammers who send them

Treachery is again in the news: forgeries, "false intelligence," con artists. Has it ever been easier to pull a fast one? Perhaps not since Gutenberg's time, or the creation of cuneiform tablets, has there been such a broad leap in mankind's potential for mischief.

Deception also presents problems in the clinic. Every doctor knows that some patients may try to scam them - to get narcotics, or disability payments, or to get sick leave. We try to distinguish beween patients who deceive for unconscious reasons (for example, to satisfy a need to be cared for), and those who deceive for obvious personal gain (for example, for money, or to hurt political opponents.) The latter often have "antisocial traits." This does not mean they are shy, reclusive types. It means that they see absolutely nothing wrong with criminal behavior that harms others, as long as their own needs are met.

In the beginning, it infuriated me. "This patient is lying!" I wailed to my supervisor, who shrugged and advised me to accept that this will happen. We are supposed to listen for implausible statements and manipulation, and try to understand what is behind them. We try not to be swayed by them.

I don't envy the fact-checkers at CBS. They have to disentangle info from so many sources now (not the least of which are the blogs, baying like bloodhounds chasing a scent). But I think a general rule is, the more likely it seems that someone will benefit from information that they have produced, the more scrutiny should be applied.....

Children of 9/11

Imagine, if you can, being a "9/11 child." Imagine being labelled and scrutinized as a "9/11 child." NYT's Andrea Elliott has a sensitive piece about these children's struggles.

Overheard at breakfast

Me: "I'm sorry I'm obsessing about my blog."

Mike: "You keep saying that. You're obsessing about your obsession."

Plaid pancakes

Oldfan's comment is reminding me of my undergraduate days at engineering school. I was young and broke, but I had a scholarship. Women's enrollment had been growing, so I wasn't a pioneer. As luck would have it, I was geeky enough to fit in. (This was when computers mostly spoke to us in ones and zeros.)

In my quest to maintain confidentiality, I haven't named the school, but someone might recognize it. A yearbook from that era suggests Dilbert in his formative years. "...the first waffle iron was just one Scottish man's attempt at making plaid pancakes..."(this, from the Industrial Engineers, in a discourse on the history of technology). From Mechanical Engineering, a plea: "Look, I just want you to get a feel for the concepts before you start designing amusement park rides." From Electrical Engineering: "At this point, while we're solving this equation, let's remember the right-hand rule: take the eraser in your right hand and go to work..."

Have those lines been passed from one generation of engineers to the next? For me, they will always evoke a time and place etched deeply in my mind. Later, in med school, I found that the engineers had trained me well in basic sciences. I had learned about hard work, problem-solving, and nerdy giggles. I could focus on other things....like, how to be a doctor.

Here's more from Industrial Engineering: "...(next) we have the invention of the electric toaster. The first designs were rather crude, consisting merely of a baker sitting in a micro-wave oven with a loaf of bread under each armpit....The electric popcorn popper (was) quickly devised as a fast and more viable alternative to setting an entire cornfield on fire to bag some popcorn for the ballgame." "The first electric clothesdryer appeared in 1815 about 500 feet out back from Mother Murphy's Flophouse, where she hung the laundry on a nearby telegraph line. The full enclosure feature was later added to keep the birds out. The much later tumbler dryer had a reputation for bouncing aimlessly about the house...."

Why the "-ette?"

I've been asked to consider why some women "debase themselves" with diminutive feminine suffixes, when creating blogs.

I won't speak for other women, but as for myself, I admit: "Confident, Strong, Liberated Female Psychiatrist" does sound better. But it would be too hilarious to anyone who knows me.

9/11

Ann Althouse has a moving post about her experiences that morning. On the West Coast, it was near dawn when I heard NPR report the first plane striking. Then I heard a stunned Bob Edwards say to a witness, "Another plane?" I shot to the TV. I sat, frozen, and watched both towers come down. I was shaking, horrified. It was still early morning. My husband was in Baltimore, and was supposed to be flying to D.C. that morning. Was he all right? A quick phone call, yes, he was fine, but trapped at the Baltimore airport, staring at CNN. Love you. Bye.

I was supposed to be heading out for work at the hospital, and there was no time to process what was happening. New patients had been admitted, they were waiting for me, their stories had to come first. Staff trickled into the ward...some of them hadn't heard any news. Some asked, what's the World Trade Center? I had known the towers as a tourist might. They meant New York, they meant America, they meant thousands of people inside...

Gradually, I could see people begin - but just begin - to grasp what what happening (particularly when the Pentagon was hit). Doctors, nurses and staff became more disturbed and distracted, our eyes gravitating toward the TV in every hospital room. Patients - all patients, throughout the hospital - were frightened and agitated - "Where is everyone? What about my problems, my heart attack, my surgery, my hallucinations?" Yes, of course, we will help you...(but what is happening out there? Who is helping those victims in New York, in Washington? And who is looking after the rest of us?) My husband got home fine - a week later, of course. And life goes on, as Ann says.....

In memory, it is akin to a natural disaster. I have to remind myself that it was an act by people. That is the value of Glenn Reynold's post; he reminds us that we have enemies, a fact that I too easily edit out of my consciousness.

Of course, it's a hoax...

Here is the disclaimer from the Kinsey Institute. Parenting does not affect IQ.....funny how none of the parents or child psychiatrists I consulted were disputing this, though....In fact, some were eager to agree. One said, "I figured the baby talk must get to them!"

Seen on "DB's Medical Rants"...

...a medical weblog:

"Those are my principles, and if you don't like them....well, I have others." -Groucho Marx

"Psychiatric mudslinging in the presidential campaign"

Dr. Sydney Smith, a family practitioner who authors Medpundit, explores "Presidential Head Games" on TechCentral Station. She cites concerns and rumors about the candidates, including Bush's drinking, and Kerry's "Vietnam nightmares."

She notes that, while certain aspects of a candidate's medical record are fair game, and other aspects are trivial and need no disclosure, "a candidate's mental health record is a dicier call... Severe mental illness can certainly be as detrimental to a candidate's ability to perform in office as a physical illness. No nation can afford a leader who is paralyzed by depression or anxiety, or whose judgment is distorted by substance abuse. Mental illnesses tend to be chronic and unpredictably recurrent." She cautions us about being judgmental, and notes that many patients do successfully recover.

She asks, "Does it matter that George Bush is an alcoholic? Would it matter if John Kerry has post-traumatic stress disorder? It depends on how well they handle it. We know that Bush is an alcoholic, he freely admits it. And that admission is the first and foremost step in the successful treatment of any mental illness. We don't know if John Kerry left Vietnam with lasting psychic wounds. He only evades the question when asked." She finds the evasion disturbing: "It suggests that he has yet to come to terms with the question himself."

I'm wondering if any soldier left Vietnam without lasting psychic wounds. And I wouldn't wait around for Kerry to tell us if he has come to terms with psychic wounds. Any admission of emotional trauma, of course, would be deadly for a campaign, and give tremendous ammunition to opponents. I'm reminded of the comments to my "Sick at Work" post, in which I am told quite bluntly about the the realities that attend the slightest admission of "stress" on the job, and those were not commander-in-chief-type jobs. We are watching Kerry in a state of major, relentless stress, right now, and we should be trying to discern how he thinks, and how he functions. What, in his daytime functioning, suggests that the nightmares are a trigger for concern?

Portraits of the fallen

Today the New York Times published photos of soldiers who have died in Iraq. Their faces cover more than 2 pages, and for those with no photos, names are listed. There are faces of men and women (the women are harder to find), some staring, some grinning. It seems impossible that there could be so many. I tried to look at each one, the eyes, the smiles, the names. Each photo suggests a world of pain and loss, a grieving family, parents, wives, husbands, children. I'm uncertain of the word "fallen" - a euphemism, a conceit - but I hope it conveys some dignity. These pictures will stay with me, when I think about this election......

Bedtime, kids!

Go to sleep! Goodnight! (Are they safely away from the computer? Okay, check out this study by Indiana University researchers, which purports to show that parenting drops one's IQ more than a few points....Now how are we to think about this? I asked a neuropsychiatrist friend about it, and he e-mailed me, "Beats me! Maybe before I had my three kids, I would have had the intelligence to figure it out!")

The computer in the consulting room

There's a new intruder in the office. Our clinic has switched to computerized records. Psychiatrists must search the computer for lab results, medication lists, and progress notes. I had hoped that all this could be accomplished without the patient sitting in front of me, waiting patiently....but, alas....

Perhaps the patient has a troubling side effect. What are her meds now? The patient was in the ER Friday, where is the report? Click, click....my gaze is diverted to the screen. The close, undivided attention that we were trained to give the patient.....now directed at a PC on my desk. Click, click....This is terrible!

The patient sits. I tell her, "It's not supposed to be like this, with the computer...." and the patient nods. I make a nervous joke. "What did the doctor do at your visit? Well, she looked at the computer," and the patient laughs. Briefly, we are allied against the machine. I invite the patient to look at the screen with me. "Here is the list of your meds, does that look all right? Here is your lab result." This machine can be tamed, we will bend it to our will. (Or will we?)

Until they replace me entirely with a PC (I envision a large screen that says, "Tell me about it!" and "It's not supposed to be like this, with the computer taking up so much of our visit...") - they could outsource my job that way, actually...anyway, until that happens, I resolve to keep the distraction of the computer to a minimum. But when they take away our paper chart, (sometime next year,) I may have to type on a keyboard while the patient is talking to me....oh, horrors. Never!

Zell: passionate, stirring, loyal, disloyal, dishonest, or...."crazy?"

Why do some people turn to the "C"-word when they are confronted with angry, vigorous opposition? Fortunately, we are hearing less of that word this week, and people are focusing on the merits (or lack of merits) of Zell Miller's arguments and accusations. Here's a comment from a fellow blogger, "Ontario Emperor":

"I don't have the details in front of me, but many presidential candidates have been accused of being insane because of their views. William Jennings Bryan comes to mind. While some practitioners participated in newspaper questionnaires about the sanity of particular political candidates, others refused to participate on the grounds that they had never examined the patient."

During the speech, I occasionally felt as if the senator was firing verbal cannonballs into my living room, but I would not use the word "crazy" to describe him. On further inspection, none of my furniture was damaged during the speech....the damage to his opponents, however, is still being calculated.

Comment of the Day

Regarding the post about the NYT, about stress in the workplace:

"Any and all inquiries into my private affairs, mental state and personal opinions on non-work issues from my employer would be met with brilliantly effective obfuscation (trust me, I have 26 year experience in government service). They would hear exactly what they wanted to hear: that I am in need of ZERO assistance to cope with the 'sub-minimal' on-the-job stress that I handle with ease. This assures my continued employment (seasoned veterans are hard to find) - unless I take umbrage at such an inquisition and take my talented self elsewhere.

"Your well-intentioned musings display a stunning lack of experience in the realities of the workplace: if it become too hard or too costly to employ somebody, then they will do without that person or the company will simply fold (or move to Taiwan). In addition, the more stringent the demands for such interventions as you contemplate, the less likely that anybody other that empty suits with a good line of BS (no, I am not in marketing - I am an Engineer) will get hired." Read the whole thing.
It pains me that anyone would have to work under these conditions - where the only acceptable response to illness-inducing stress is, "thank you sir, may I have another," or a stoic insistence that things are perfectly fine, thanks. I'm sure this man has facts to back him up, and that everyone in the mental health field should realize exactly what is at stake if an employee dares to admit to certain employers that stress has become an issue. (I'm not sure why he's stunned at my naivete, though....I'll admit that to anyone!) We do sometimes see patients who are so stressed that they are no longer able to function at work, and are no longer able to disguise that fact. Many employers actually surprise their workers in these circumstances, when it turns out that the employers are actually not ready to dump them....they try to be flexible with hours and sick leave, and try to help reduce conflicts. (That was clear, even in the NYT article.) But of course, not all employers are so understanding.....(It especially pains me that engineers would have to use obfuscation in the face of unreasonable stress. I completed my undergraduate degree at an engineering school.)

Public Service Announcement

This is for people who take antidepressants (with apologies to those who already know about this....)

Before stopping antidepressants suddenly, please talk to your doctor.

Ask the doctor what will happen if you stop them suddenly.

Ask whether you might experience "discontinuation syndrome," which might include dizziness, lightheadedneess, anxiety, agitation, irritability, lethargy, headache, vivid or increased dreaming, impaired short-term memory, insomnia, nausea, fatigue, and poor balance.

Thanks, Ann.....(I think!)

I started this blog 3 days ago. I was up most of last night on call, and then had my office clinic. Now, checking in, I see that Ann Althouse has noticed me! And there are comments! Thanks to everyone....this has been quite, quite unexpected.....but I'm too sleep deprived to think. Good night, all.

A detective who collects suicide notes

He's puzzled by the most chilling one....
(Did you know that if you Google "suicide note," you find sites that offer editorial assistance?)

But...I thought I would only get spammed!

I'm amazed by the comments I'm receiving. The post that I deleted, was miraculously re-submitted (thank you!):
"Patricia said...
Was that my post? I think this is what I said, LOL.
I think you are correct about the macho aspect of politics, but maybe all striving or competition, whether in business, sports, or politics is exactly that. It’s a metaphor or a rather fragile overlay that masks the essential struggle of life versus death inherent in all human endeavor. I’m thinking about this because I just saw Open Water--I have a degree in critical studies and have read lots of psychoanalytical theory—and it’s a fabulous film. It strips down the metaphor to the essential struggle that is at the heart of life and of the violent and beautiful natural world.
Why do we keep struggling against an inevitable end? Now, there’s a true mystery."

I expected mostly silence, and I'm receiving poetry! This is so humbling...Now I'm getting paged again, to return to the hospital. (Patricia's post will inspire me....)

Another holiday on call....

Just finished my rounds. Some observations from the front lines:
1. We are still far too dependent on medications, and we are using more and more of them, in combinations that can't be supported by much research. When I'm on call, I can peek at the meds ordered by my esteemed colleagues, and I've never seen such complicated combinations of meds.
2. Medical (as opposed to psychiatric) problems are still the most common and the most overlooked causes of confusion and hallucinations in the elderly. We are still not diligent about diagnosing delirium, even when the signs and symptoms are obvious.
3. Staffing on weekends and holidays continues to be a huge issue.
4. The shortage of psych resources in Oregon is becoming more obvious. Right now, our unit is full, and it's only 5:25 pm. What will we do tonite, when patients start crowding into our emergency room?
5. Our staff still has a sense of humor. At about 3 pm, the staff spontaneously started singing together, "You Could Be Swinging On A Star," and the patients were....bemused. And perhaps entertained. But we (staff) had fun!

Aaaarggh!

I just goofed - I accidentally deleted a marvelous, thoughtful comment about the Kerry post. Someone looked at the Kerry story and started taking it beyond psychological terrain, and into a realm closer to art, philosophy, and perhaps spirituality....even speaking about film theory! I was trying to respond, and I hit the delete button (without even knowing what the delete button is. Now I know, darnit!) Whoever you are, I'm sorry.

On call today

Today I celebrate Labor Day by laboring. I am on call for psychiatry for the inpatient unit in Eugene. Fortunately, my colleagues have volunteered to assist me, giving up their own free time so the job is not too overwhelming. (Thanks Randy, Cindy, Bill, and Ed!) I only have 13 patients to see, but some of them are really sick. Okay, let's get to work.

With friends like these.....

Ann Althouse asks how Kerry can possibly follow the conflicting advice that is on offer from all quarters. (Why are his advisers adorning the pages of the New York Times with their musings? What happened to "staying on message?") Perhaps he scans the Op-Ed pages for helpful campaign advice.

(Sigh) NYT "Wonders How Kerry Became A Girlie Man"

This is Frank Rich's contribution to the debate swirling around us. I promised, "no armchair analysis," for its temptations are great, and the risks keen, and I cannot hold forth with authority about someone I've never met. Alas, Frank Rich feels no such contraints, and for all I know, he has met these guys. He believes that our candidates are playing, "Who is more macho?" and that Bush is (for now) winning, by nefarious means. Did someone out there know that I would begin my blogging career today? Am I supposed to roll up my sleeves, and get to work? Is every contest between powerful males inevitably a macho slugfest, with primitive, libidinous, murderous undertones, and is the weaker opponent always an emasculated, pitiable loser? Now hear this: there is no earthly evidence that anyone, anywhere, thinks Kerry is a girlie man; it is just a catchy headline that guarantees that people will scan the story to the end, looking for titillating gossip. And yes, they will find it.....along with talk about "castration warfare" and Dukakis dressing like "Snoopy" to ride a tank.......I can't wait to see what dear Wonkette has to say about this. In fact, I think I will go find out. Honestly, the blogging community has been all over these issues for months, and they have handled it with far less silliness than our Frank....

NYT Explores Anxiety in the Workplace: "Sick at Work"

Nice article by John Schwartz, in honor of Labor Day. Until I figure out how to link to the article, (which is on a registration-only site,) I will have to quote directly:

"Decades of research have linked stress to everything from heart attacks and strokes to diabetes and a weakened immune system. Now, however, researchers are connecting the dots, finding that the growing stress and uncertainty of the office have a measurable impact on workers' health and, by extension, on companies' bottom lines." They describe some driven employees who ultimately discovered the "hollowness" of their hefty paychecks, and calculated the huge personal costs exacted by perpetual "on-call" productivity.

I applaud their emphasis on workers taking responsibility for their health, but I do think some employers are being let off the hook too easily. The attitude seems to be, "Cope with the stress, adapt, or find something else to do." (One employee even ended up on disability when her multiple sclerosis flared up, during a period of intense job stress.)

Don't employers need to address the causes of workplace stress, and not permit stress to reach unreasonable, illness-inducing levels? (The article suggests that speed of business expansion makes a difference, as well as better-known issues like friction with coworkers, and overbearing bosses.) Unfortunately, fear of stigma and reprisals may have prevented employees from speaking out to change working conditions. How many prescriptions for antidepressants or tranquilizers might never be written, if employers only listened to their workers?

Profound, heartfelt sorrow....

for the victims of Beslan, Russia, after the horrifying 52 hour seige. I am still getting caught up on this one, as I just spent 2 days with a close friend who is grieving the death of her mother. My friend is enveloped in her own agony, and she banished the television from our midst. She especially did not want to hear any news programs, "no news of any kind, good or bad," and so I missed many details of the standoff and of the suffering of humdreds of victims. What I saw in my friend's face, I now see magnified a thousand-fold in the faces of the Russian parents. It is so far beyond what I can imagine, that I am left utterly speechless.
This wordless, terrifying sorrow has become too familiar. I had not thought we would see so much tragedy, so often, so appalling, so senseless. (And then, the inevitable question, "What next?" ----the question, I think, that the conventions were trying to answer.)

My first day blogging!

Already I can see how this might become a rather compulsive thing... I'm not showing up on the "Newly Published Weblogs" list, for some reason. And I'm flabbergasted when I scroll down the list of blogs, and see how many are out there....just on Google's Blogger! It is truly amazing. I have long felt that the most creative, most adventurous and engaging writing is not being done on paper these days.....it is being done by bloggers.

And look at all the blogs dealing with mental health....or the lack thereof!
There's "Adult ADD" (she advertises her blog as "my escape from homework and laundry," and her URL address says "distractme." I think I would like to get to know her.) And there's "Madness" in several blogs, and there's also "Insanity is a Full Time Job." I won't argue with that one.

What this blog is not.....

Okay, so I'm a card-carrying psychiatrist. But I can't diagnose on this site, and I certainly can't give advice or suggest treatment to anyone (other than "talk to your doctor!"). I can discuss various diagnoses and treatments. I can tell you what I think of various diagnoses and treatments. But I'm not Dr. Freud On-line.....I'm not even Dear Abby On-line. (I hope that will suffice as a disclaimer.)

Where I am....

(Gosh, my last post sounded pompous. Maybe this one will be better.) I live in the gorgeous Pacific northwest, in Eugene, Oregon. We are an hour from the mountains, an hour and a half from the ocean, two hours from Portland, and we are having the most glorious Labor Day today....sunny and brilliant. (Yes, we do get some sunshine in Oregon!!) I have a husband Mike, and a very spoiled cat named Andrew, who has not yet shown an interest in blogging.

Who I am.....

I am a board-certified psychiatrist who sees both inpatients and outpatients (mostly outpatients) with a wide variety of ailments. I have a particular love of older adult psychiatry. Our location, a small college town surrounded by a large, underserved rural community, guarantees a continuous, diverse stream of the anxious, the depressed, the downtrodden, and the seriously mentally ill. (We use both talk and meds, by the way.)

Greetings...

....from a dedicated weblog-reader, who has been fascinated by the electronic outpourings of others (notably Instapundit, Kaus, Juan Cole, Wonkette, and a few doctors and lawyers who blog). Now I am (finally) jumping into the fray.

Not all of my opinions are a result of my psychiatric background, but I'd say that most of them are....and, like many shrinks, I end up with more questions than conclusions. Here, I can ask those questions (not that I'm expecting any answers.)

I can examine the questions that are being asked in the media and in other weblogs, as well as the questions I'm not hearing (no jokes about auditory hallucinations, please!) What are the unspoken assumptions in a story? What are the motivations? Does Zell Miller really have a psychiatric diagnosis (as many bloggers have decreed)?

Besides, I'm curious about blogging itself. (Is it as fun as it looks?) And lest I forget....minimal armchair analysis! I promise!