Prozac and baby mice

...or rats, depending on the reporting. More animal research on Prozac, with an unfortunate lack of details so far. It's hard to know how to assess this article (note, WebMD says "mice," but this article says "rats"):

"Rats given the drug for the first few weeks of life perform poorly on tasks designed to test their confidence and ability to deal with stress, says psychiatrist Jay Gingrich, who ran the study with his colleagues at Columbia University in New York.

"Gingrich's colleague Mark Ansorge assessed the rats' behaviour by placing them in a cross-shaped maze raised above the floor, a test that measures the willingness of the animals to explore an unusual environment. Adult rats dosed with Prozac early in life were less interested in venturing far from their starting point and spent less time moving around. Animal researchers take this behaviour as evidence of abnormal emotional development.

"Related tests revealed that rats given Prozac are also less willing to take risks to earn rewards such as food and take longer to escape unpleasant environments, a sign that they deal poorly with stress. The results were revealed on 26 October at the annual meeting of the Society for Neuroscience, held in San Diego, California. They will be published in the journal Science this week."

I've always tried to emphasize to pregnant patients that we simply don't know about all possible effects of SSRI exposure. When we try to weigh the risks and benefits, we don't know all risks. What usually tips the balance: will there be a mother, and a baby, if we don't use a medicine like prozac? Will suicide or homicide be less likely with the medicine? Have all other options been explored?

I'm no researcher, but I'm not sure how you make the leap from rat behavior to rat emotions. I suppose that if the "risks" were actually risky for the non-medicated rats, such that some were injured by their risk-taking, then the survival rates of prozac-exposed rats might be higher. Just the fact that rat behavior changes, though, is enough to give me pause. We'll have to wait until the research is published this week. And for its real significance, as the article says, we'll have to wait until there is more research on humans who were exposed as fetuses. Our "cautious" prescribing behavior will become yet more cautious. Like the rats (or mice?) treated with prozac, I am exceedingly risk-averse.

(update - my google search reveals more articles saying "mice" than "rats.")

(another update: here's a link to the journal article.

Message from the front lines, #2

Some e-mails are haunting. How should I respond to this reader?
"Shrinkette, My wife and I adopted a brain-injured child when he was four. Today he's 30, and between the nasty things that were done to him before he was two and the nasty things he's done to himself since then (alcohol, marijuana, crystal meth), has some serious problems. Since he's legally of age, we have little input into his health care. He's being prescribed some pretty powerful psychotropic drugs for several different problems. With his documented brain damage, it's difficult for him to remember to take his medication on time, or even to take it at all. He's extremely resistant to our control, so the medication isn't doing much good. There's no type of facility where he can be ordered to remain on the grounds and be cared for by an independent staff, so he drifts. Eventually, this will kill him. Needless to say, I'm developing a long list of politicians, professional 'do-gooders', and medical practitioners who have abetted this situation. One day we're going to have to realize that "one size fits all" does not now, nor has it ever, fit medicine."

Musicians and performance anxiety

Before we get too exercised about musicians calming themselves with beta blockers, let's acknowledge that physicians have been known to take these meds themselves before stressful occasions. (I have one friend whose propranolol wore off about 30 minutes before his board exam, much to his dismay...) Athletes and public speakers have been known to use them as well.

Both Medpundit and bookofjoe have weighed in on this topic. It seems obvious that self-medication is hazardous, that a level playing field is desirable in competitions, and that performance anxiety should be addressed as part of musical training. This article from "American Music Teacher" seems to have a sensible approach. The author, Anne Petrovich, is a violinist and psychologist. She has this to say:

"What differentiates musicians who thrive on performance from those who dread it and suffer the disabling effects of severe performance anxiety? Contrary to commonly held, and often comforting, beliefs, the amount of technical practice and preparation, the degree of talent and the excellence of professional training with the "right teacher" are not factors that differentiate the confident from the terrified performer. "Preparation, preparation, preparation," or "practice, practice, practice," though important and necessary conditions for an effective performance, are insufficient mechanisms for coping with the anxiety involved in severe stage fright. What the exceedingly nervous performer needs is not only musical preparation, but also a way to manage the anxiety engendered by the performing situation.

"...anxious students will interpret almost any physiological signs of anxiety as harbingers of an impaired performance. Moderate physiological arousal enhances performance, if interpreted by the student as alertness or preparedness. Too much arousal, such as shaking hands, pounding heart, profuse sweating, lightheadedness or other elements of the fight-or-flight response, impairs performance. Self-efficacy is strengthened whenever a musician can reduce the degree of physiological arousal to a manageable level...

"...There are three important points for teachers to remember when discussing with students the use of medication to control anxiety: first, medications should be dispensed only by physicians and not "shared or borrowed" from other sources; second, students whose anxiety is so severe that medication is needed should never be shamed or made to feel inferior or guilty about using a drug; and third, care should be taken not to describe the medication as all-powerful, because the performer may then attribute a successful performance only to the drug, thus reducing his own sense of self-efficacy for managing anxiety. Medical interventions are best used, if at all, as part of a range of coping techniques incorporating all the self-efficacy sources. When considering physiological/emotional arousal, the overall goal should be to help the student learn to control the amount of arousal experienced and to interpret arousal as enhanced preparedness." She also describes behavioral techniques to help manage the anxiety.

Was the music teacher cited in the NYT article fired for having the sort of discussion that Dr. Petrovich describes? Teachers and prescribers could probably find a way to work together on this. But with some caution, of course; these meds are not entirely benign, as Dr. Rangel says:

"**Medstudent and Resident Alert - Beta blockers may not kill off your social life but they can still cause the following: Worse CHF during an exacerbation, heart block (especially if used with other negative chronotropic agents), bronchospasm (even if selective agents are used), worsening peripheral vascular disease, and they may impair the ability to recover from exogenous insulin induced hypoglycemia and mask symptoms of hypoglycemia in diabetics."

On confidentiality in blogs

I sympathize with Dr. Charles, who agonized about "the tied hands of the physician writer." We have hundreds of stories to tell. But how to disguise the data, so that patients don't recognize themselves? I could start with a straightforward post: a history, a symptom, an anecdote. (I have edited this quite heavily since first posting, because....well, because I was worried about confidentiality, and the tone bothered me. Levity is not respectful sometimes, and this was one of those times.) How much do I have to alter clinical information, before launching it into the blogosphere?

I had a hypothetical somatic delusion all worked out, as an example. (All right, it was silly.) Then I thought, oh gosh...someone, somewhere has that symptom. And we aren't just talking among friends here...someone knows someone who has that symptom. They will read this. They'll start talking. Someone will say, that's what happens to mentally ill people! It will appear here and there...it will turn up in Google searches. How to proceed with medical blogging?

Recent posts about privacy have tended to focus on doctor's liability. I'm thinking about the effect on patients, on people who have embarassing symptoms, who will see our blogs and think, "oh no..." And the jocular tone of my blog..."The psychiatrist is laughing at me! The blogosphere is laughing at me...I've become entertainment..." Oh, horrors. Not everyone, of course, will feel that way. But if someone does....

I won't be able to to attend Bloggercon this year. I hope they can spend some time on this issue. We could use a little help here.

On-call dreams

Restless...mmmph...Dean and Moore wearing Kerry masks, leaping from shadows....My Pet Goat on O'Reilly's show, giving endorsements...Osama on the phone, asking if I've mailed in my ballot yet...Kerry running a lemonade stand in the front yard...free lemonade for the middle class...Bush blowing up lemonade stands...Bush brings lemonade to the Middle East...vote fraud reported in every state...ballots disintegrate, election results declared invalid...Bush, Kerry, and Osama all declare victory...national psychiatric emergency is proclaimed.
Is that my pager going off?

On internship and sleep

How to respond to "news" that sleep-deprived interns make more errors? Just as Eskimos have multiple words for "snow," doctors can hold forth about multiple forms of fatigue: the tiredness that accompanies one hour of sleep, or two, or three, or none. The tiredness of disrupted sleep - one crisis, or two crises, and so on. The tiredness of being on call every other night, or however many nights per week. The anxious, irritable tiredness when everyone is crashing at 0300 and nothing is going well. The happy tiredness near the end of call. The numb fatigue post-call, while roaming through a parking lot, trying to figure out where on earth you parked....

Somehow, during those endless, agonizing shifts, generations of doctors were transformed. Sleepless, helpless, acutely ill patients journeyed through night after night with sleepless interns. Seeing illness up close, so intimately, so directly, and so intensely, changes something in the intern. There are social and cultural aspects - bonding with other interns who share your burdens; becoming one of the tribe, through hazing. And there are psychological aspects: "Now I am the doctor." Doctoring becomes second nature, bypassing the daytime brain. The experience contributes to a gulf between doctors and non-doctors, which persists throughout our working life and beyond. One only has to read a few entries at intueri to get a small glimpse of the experience...even now, after legislation to reduce intern work hours.

My opinion of those call schedules? The gain is not worth the pain. The hours are abusive. They destroy relationships. A well-rested intern can make grievous errors; why take more chances with a tired one? Still, I never thought I would see the old system change. Is change finally occurring? Perhaps the financial incentive of cheap intern labor is finally outweighed by the risks of their sleepy errors.

As Dr. Centor notes, in bringing down these old systems, we change care delivery. Imagine being desperately ill, and seeing a longer parade of young interns come and go. Who's the captain of this ship? Who knows the big picture? (If patients think that care is impersonal now, just wait...) It's also a change in the experience of becoming a doctor, and of being a doctor. We will be team players, with all the opportunities for discord and dysfunction that one can imagine. Will there be a corresponding change in our attitudes, our "lone ranger" tendencies, our entitlement? Will the gulf between doctors and the rest of the world become smaller?

Tonight, as an attending on call, not much has changed for me. Familiar forms of tiredness will settle over me, and inhabit my brain, as they did during training. The ER is calling again...I don't expect to get much sleep tonight.

And no one had better wake me up to ask me for a sleeping pill!

(to clarify - there are no interns or residents at our medical center; on-call duty belongs to attendings who take turns.)

Update: excellent commentary on this topic at A Chance To Cut Is A Chance To Cure.

French analysis of America...

"It's transference. The French have transferred their psychology of decline to America, so they feel better," he said. "Now they have a mission: They are going to defend mankind against the United States." And more transatlantic interpretations, at Slate.

"You can't beat The Shark and the Seagull, by former Foreign Minister Dominique de Villepin, for the author's way with metaphor...(I'll let readers guess which country is which in the book's title.)"

Message from the front lines, #1

A new psychiatrist responds to my post about children and antidepressants:

I think you're right that we don't give our primary care docs proper support. Here in Alabama we have a dire shortage of psychiatrists, even in Birmingham (which has the highest density of shrinks) it is a 2 month waiting period for new patients. The psychiatrists down here are also bad about getting back in touch with their referral sources, and often leave them in the dark about what they are prescribing and why.

I finished my general psychiatry residency in June '04 and have been quite successful in my all outpatient practice so far. I send a thank-you back to my referral sources with my recommendations and treatment plan and this has been very well received. Sometimes it is scary to see how much psychiatry gets practiced in primary care with so little formal training. In a perfect world every case of depression would be treated by a psychiatrist, but the fact is there is not enough of us to see all of them. We need our primary care doctors to feel confident in prescribing antidepressants.

As far as the FDA is concerned, I think the black box warnings are going to kill a lot of teenagers who otherwise would have gotten an effective treatment. I know pediatricians down here that are reluctant to prescribe antidepressants now. Seemingly ignored is the fact that as antidepressant use has increased over time the suicide rate has declined, as well as the fact that in the 4,250 patients in the studies cited by the FDA *no one committed suicide*!

I'm also bothered by the catch phrase "close monitoring" of patients on antidepressants. What the heck is that? Does that mean having every patient I have on an antidepressant leave me a voicemail in the morning letting me know they are still here? Or seeing them back in 4 weeks instead of 3 months? Or insisting that they get psychotherapy every week? I can see the trial lawyers just foaming at the mouth over this one....

Thad

6:22 AM

"Doctor, we have a problem..."

Doctor, are you known as the "Mount St. Helens" of the medical landscape? Does your staff don protective gear before telling you bad news? In this month's Psychiatric Annals, Dr. Larry Harmon, PhD, and Dr. Raymond Pomm, MD, report on "Evaluation, Treatment, and Monitoring of Disruptive Physician Behavior." It's not available online. Here are some excerpts:

"Disruptive behavior includes such conduct as using foul and abusive language, threatening associates, criticizing staff in public, and relying on intimidation to manipulate others. Recent case law defines disruptive physician behavior as conduct that 'disrupts the operation of the hospital, affects the ability of others to get their jobs done, creates a 'hostile work environment' for hospital employees...or begins to interfere with the physician's own ability to practice competently."

They report that one survey of perioperative nurses found "91% experienced verbal abuse by physicians," while another survey reported "92.5% of nurses had witnessed disruptive behavior, the most frequent being yelling or raising the voice, disrespect, condescension, and berating of colleagues." They note that mood disorders and personality disorders are often present, especially those with narcissistic and obsessive-compulsive traits.

(Yes, of course, say the nurses; we know all this. But what can be done about it? As the president's advisor said, "I prefer to let others run into the propeller...")

These authors are trying to dismantle the propeller...or at least slow it down a bit. They report on a survey program that aims to identify disruptive physicians and provide feedback about their workplace conduct. The program, called PULSE (for "Physician's Universal Leadership Skills Survey Enhancement"), asks healthcare and medical staff to complete "interpersonal skills" surveys on individual docs. They're presented as an "early warning" system to "modify conduct before it becomes subject to disciplinary action." "Physicians whose conduct ratings are in critically unfavorable ranges may be encouraged to obtain assistance from various sources such as...state physician health program, local mental health professionals...a stress or anger management program, or a 'workplace coach.'"

My guess is that most docs who receive such "encouragement" will realize that disciplinary action may ensue if they don't comply. Florida has a system that balances the need to address impaired MD's and prevent them from harming patients, while protecting the confidentiality of the docs. It's a system that more states should adopt.

Here are some resources provided by the authors.
For evaluation:
Physicians Development and PULSE Survey Programs
Professional Renewal Center
Vanderbilt University Center for Professional Health
For education:
University of Alabama Health for the Healer: 205-975-7931
T.E.A.M. Program
Distressed Physician Program, Vanderbilt
For inpatient/residential treatment:
Talbott Recovery Campus
Professional Enhancement Program, Pine Grove Treatment Center
Center for Professional Excellence
Professional Renewal Center

With liberty and "medical marijuana" for all...

I'm wading through Oregon Ballot Measure 33, which amends the Medical Marijuana Act of 1998. The measure would "allow the creation of licensed non-profit dispensaries regulated by the Oregon Dept. of Human Services to produce, possess, and sell marijuana to registered patients and/or caregivers." The measure requires a program for indigent patients to receive free medical marijuana from licensed dispensaries (the program would be funded by proceeds from the sale of medical MJ). There would be penalties for distributing inferior product, too...no "seeds, stalks, and roots of the plant or any contaminated marijuana or any male marijuana plants or any marijuana clearly intended to be discarded..."

The amount of allowable MJ would be increased to "10 plants and one pound" per registered patient and/or caregiver per year, unless it's harvest time (one crop per year!). Doctors may approve a larger quantity. The accompanying arguments state that "the 10 plants plus 1 pound allowable...equate to a total of 12,936 marijuana cigarettes...(this) would be equivalent to smoking 1 1/2 joints every hour of every day in the year." (Is that so?) Naturopaths and nurse practitioners would be empowered to authorize medical MJ. And the list of approved conditions is expanded to...well, to anything, if your prescriber approves.

Between the menacing wolf TV ads, we're seeing ads that feature disabled patients, explaining how they can't grow their own marijuana, and how the measure would help them. Most everyone I know shrugs and says, "What do we care if chronically or terminally ill patients are high on pot?" But free, state-mandated pot to registered, approved, indigent patients...

For what it's worth (and who knows what it's worth anymore), here's the National Institute on Drug Abuse, on marijuana. The Oregon Medical Association opposes the measure, noting lung damage and carcinogens in marijuana smoke. There's always ingestion...wait, here they say that the British Medical Journal reports that "medical literature has shown an association between marijuana smoking and illnesses such as depression, schizophrenia, and suicidal ideation." And what's this..."Libertarians say vote no on Measure 33." The measure "puts government where it doesn't belong, between the health care professional and their patients."

I once saw a patient who was taking legally prescribed amphetamines, tranquilizers, opiates, and medical marijuana. Why was the patient seeing me? Because the patient did not feel good. Anyone who thinks that medical marijuana is a panacea, will likely be disappointed. And what do we know about interactions between marijuana and other meds? Answer: not much. The measure requires research into the efficacy and safety of medical marijuana. I usually prefer that the research precedes the prescribing....
If, as the OMA suspects, this is simply drug legalization in disguise, there will be plenty who don't care. How will Oregon voters (myself included) decide this one? To be continued....

Battleground state

Oregon's mail-in ballots arrived this week. Overnight, we've seen a cascade of new political ads, phone calls, and visits from earnest volunteers. Menacing wolves eye us from the TV. The chirpy DNC caller wants us to help "collect ballots." Would we like to attend a special screening of Michael Moore's movie? Or perhaps send a donation?
"The story has changed," says Doc Searls' sister, who thinks we're seeing a Bush recall effort, not unlike the Grey Davis recall. "It is not about the candidates anymore. That is just cursory coverage of their bus-embedded reporters, and equal-time sound bites...
"The story now IS the election. The election process. Not only the dangers of chaos, early-voting, registration mess-ups, the stolen signs, the various scenarios of a challenge to the results, the legalities and the larcenies.
"The real story is the engagement of the people. The passion to recall. The fear of change or the unknown. The push to get the youth out. The lack of the population's ennui amidst their fatigue from the rancor.
"The recognition that, whomever you're voting for, the stakes are too high.
"And that the prime lesson learned from 2000 is that every vote CAN count."
At our doorstep, the resolute volunteer informs us that the visits will stop when our ballots are mailed. I don't really believe her, but that's more incentive to vote already. Now, where did I put that thing? Wait, someone else at the door...

Healing ourselves?

Some eye-opening data from this month's Psychiatric Annals, devoted to "Physician Health and Impairment." Dr. David B. Feller, MD and Dr. Robert L. Hatch, MD, MPH, ask, "Do Physicians Take Care of Their Health?" Not very well, it seems:

"Several surveys have measured the proportion of physicians who have their own health care provider. Results indicate only one-third to two-thirds of physicians have a health care provider of their own. Several factors suggest that the percentage is even lower than this. The response rates to these surveys were somewhat low (40% to 77%) which would tend to underestimate the presumed "bad response" of not having your own physician.

"Furthermore, even when physicians reported having their own physician, 30% of the time it was their partner, and 12% of the time it was themselves...It has been estimated that 82 to 86% of the general population has a regular health care provider."

And as for self-treatment: "According to Sir William Osler, 'A physician who treats himself has a fool for a patient.' Today's physicians appear to agree - only 7% of physicians agreed with the statement, 'Doctors make few mistakes when treating themselves.' Nevertheless, multiple studies have demonstrated that the majority of physicians do treat themselves. Resident physicians display similar behaviors: 52% reported self-prescribing, with 42% of self-prescribed medications obtained from the sample cabinet." Another common practice, in my experience, is for one MD to approach another with a blank prescription pad, saying, "I think I have bronchitis; would you be willing to write for some antibiotic?" The doctor receiving the entreaty is often flattered and accomodating, and the result is disguised self-prescribing.

I have colleagues who think nothing of walking into a drugstore, saying, "I'm a doctor, and I'm writing myself this prescription." But I have never been able to do that. Instead, I engage in the vastly more uncomfortable exercise of being a "Sick Psychiatrist Visiting Their Doctor..." no doubt, as uncomfortable for the treating provider as it is for me. The pressure to not have medical problems (or, if there is a problem, to have an agreeable and easily treatable one) is immense. As noted in this month's Annals, the problem is immeasurably greater when the issues are addiction or behavior problems...which sounds like a good topic for a second post. To be continued...

Lancet looks at mental capacity....

on medical wards, and finds that patients are often more impaired than we think. Often, ill patients nod their consent to us. "Sure, doc, your plan sounds good to me." But how many are really comprehending us? Impairments are more likely to be noticed when a patient is refusing tests, or resisting treatment. Then we get a call. "Is this person competent?" Right off, we ask: competent for what? Impairments can vary, and sometimes fluctuate. They can be general and total, or they can be quite specific. And the processes patients use to make decisions can be mysterious.

At the Institute of Psychiatry in London, researchers interviewed 159 patients on acute medical wards. The article states that thirty-one percent showed impaired ability to make valid judgments. But staff recognition was low: "... only a quarter of patients identified by the investigators as not having mental capacity were identified by clinicians."

"Professor Hotopf comments: “A substantial proportion of inpatients in any general medical ward do not have capacity to make informed treatment decisions, a situation that is rarely recognised by doctors. If a legal approach to solve this problem is too heavy-handed-eg, requiring patients to be more explicitly identified and protected-then people who would be affected by such legislation could be adversely affected.

"However, to accept the passive acquiescence of such patients as evidence of true consent would be dangerous when important and irreversible decisions need to be made. Before making such decisions, the clinician should have considered the possibility that the patient is unable to give valid consent”.

"In an accompanying commentary (p 1383), Jason Karlawish (Institute on Ageing, Philadelphia, USA) concludes: “The critical issue is how we use these data to regulate the freedom to decide, especially in elderly people with mild stages of cognitive impairments. Data are not available but are urgently needed to answer the following questions: What information do raters use, how do they use it, and what are the consequences of these differences? Do experts, clinicians, and families still disagree on capacity judgments, even with the same information and judgment question? Wht are the ethical, legal, and clinical consequences of these disagreements? How do clinicians' and families' failures to recognise impairments in the capacity to make decisions affect quality of, adherence to, and outcomes of care?"

Verichips in song and verse

From the Public Health Press:

News Links 10.14.04

1. "What's the frequency, Doctor?" time for Benzedrine, uh-huh
I am branded, scanned, marked, implanted with a seed
You know you'll be pegged from cradle to dream
Privacy advocates mad start to scream
Don't underestimate the consequence, uh-huh
You'll wear your history like a letter "A", uh-huh
(source)

...and more medical news in rhyme.

Hat tip to Over My Med Body!

Microchips, mega-concerns...

Implantable microchips may soon provide doctors with access to your medical records:

"A microchip that can be implanted under the skin to give doctors instant access to a patient's records yesterday won government approval, a step that could transform medical care but is raising alarm among privacy advocates.

"The tiny electronic capsule, the first such device to receive Food and Drug Administration approval, transmits a unique code to a scanner that allows doctors to confirm a patient's identity and obtain detailed medical information from an accompanying database." (10/14/04, Washington Post, via Yahoo News.)

Is this a good thing? Consider that some encounters go something like this:

MD: "What meds are you taking now?"

Patient: "I think it begins with L."

MD: "Lasix? Lanoxin?"

Patient: "I think it has an 'L' in it....say some more 'L' drugs, and I'll tell you which one it is."

Such dialogues make us yearn for readily accessible information. If a patient is disoriented, unconscious, or acutely psychotic, the hunt for data is hugely difficult, and more critical. Are implanted microchips the answer? Who gets the chips, who gets the scanners that read the chips, and exactly what data will be retrieved? I'm googling this today, and finding that the debate is in full swing.
Here's more:

"Doctors would scan patients like cans of soup at a grocery store. Instead of the pie, the patient's medical record would pop up on a computer screen. Emergency room doctors could scan unconscious car accident victims to check their blood type and medications and make sure they have no drug allergies. Surgeons could scan patients in the operating room to guard against cutting into the wrong person. Chips could be implanted in Alzheimer's patients in case they get lost."

I'm wondering, how is the database maintained? Even now, with electronic medical records, med lists may be incomplete, allergies missing, dictations pending. If the database isn't current, we might not even have the letter "L" to suggest what the meds are. Patients now have the right to request changes in their medical record, so the database might reflect only what the patient chooses to share. The patient's name would presumably be correct, and sometimes that alone might justify the chip.

Can we safeguard privacy with the chip, as we now protect medical information?

"The approval was immediately denounced by privacy advocates, who fear it could endanger patient privacy and mark a dangerous step toward a Big Brother future in which people will be tracked by the implants or required to have them inserted for surveillance, identification and other purposes.

"Once the technology is out there and is available, it raises the very real possibility that people in a position to require or demand it will begin to do that," said Katherine Albrecht, who has campaigned against such devices. "It would obviously be possible to inject one of these into everyone. In the post-9/11 world, we are already racing down the path to total surveillance. The only thing missing to clinch the deal has been the technology. This may fill that gap."

But if patients control the medical data in the database, and permit the scanners to retrieve the data, how does this violate privacy? I suppose the scanners and database might fall into the wrong hands. The same is true of paper charts, and the same safeguards presumably apply.

Here's the company's chief executive, discussing privacy:
"The accompanying scanners and software ensure that the personal information unlocked by the 16-digit code is only available to those designated by the patient, Silverman said.
"Even if people access your unique identification number, which would be extremely difficult to do, it doesn't give them access to your database. We're confident in the security measures we've taken," Silverman said.

The article also raises the issue of autonomy. Can patients be compelled to receive the chip? As I understand it, patients or their guardians must give consent for any injection...why not the chip also? (I don't see much discussion about chip removal - how difficult it is, how practical, or what complications might occur. If one can consent to the chip, one should be able to request its removal.) But critics warn that chips may become compulsory (in prisons or high-security situations in our post-9/11 world).

The company is optimistic about its future. "We believe that this (medical) application is going to drive acceptance of the product," said Angela Fulcher, vice president for marketing and communications. "If you have a chronic disease, where getting information to health care providers quickly may mean life or death, that population is going to be more accepting of this technology."

(Afterthought: As interns, we used to joke about the tattoos we wanted: "no code" on our chests, "no tubes" inscribed in our throats, "no cut-downs" over our veins. Perhaps tattoos won't be necessary, and microchips will express our last wishes clearly.)

(Update: Symtym beat me to this. According to his sources, it looks like the devices aren't easily removed.)

Senate race puzzle, part two

Update: I caught part of the Kentucky Senate debate on CSPAN. (My last post discussed concerns about the actions of Senator Bunning, who is running for re-election.)

Sen. Bunning made a reference to "confronting our good friend, Saddam Hussein." His bemused opponent mildly replied that he did not consider Saddam a good friend.

Sen. Bunning offered an apology for comparing his opponent to Saddam's sons (!), and asked his opponent to apologize for smearing him with accusations about Bunning's medical condition.

His opponent, who is a physician, had a good answer: that he's not behind any smears about Bunning's health, but that he thinks Bunning's conduct has been inappropriate.

Yes! That is where the focus should be: on conduct, on behavior. I hope the focus stays there...

A puzzle in a Senate race

Mary Jacoby at Salon reports on perplexing behavior of a Kentucky senator who's running for re-election. The 72-year old senator has long been considered a shoo-in. But apparently, since February of this year, there are concerns:

"Oct. 12, 2004 - It's no secret in Kentucky that Sen. Jim Bunning, a Republican who was expected to coast to reelection on Nov. 2, has been acting strange. Over the past few months, Bunning has angrily pushed away reporters, exchanged testy words with a questioner at a Rotary Club and stuck to brief, heavily scripted remarks at campaign events, delivered in a halting monotone. The former major league baseball star now travels the Bluegrass State with a special police escort, at taxpayer expense. His explanation? Al-Qaida may be out to get him.

"More substantively, the incumbent would agree to only one debate with his Democratic challenger, state Sen. Daniel Mongiardo. And the rules Bunning negotiated were bizarrely rigid: The encounter could not be live; the taping has to occur in the afternoon, not the evening; no audience could be present in the studio; and, under threat of legal action, Mongiardo could not use any sound clips or video of Bunning's debate performance in campaign advertisements.

"This apparent fear of the spontaneous has spurred rumors in Kentucky that Bunning, a member of the Baseball Hall of Fame, is suffering from some sort of dementia, perhaps Alzheimer's..." Ms. Jacoby goes on to describe further examples of troubling behavior.

I often see families who are trying to understand and cope with an older relative's behavior. I like challenges like this. Is there a significant change in the mental state of the patient? If so, why? The first step is always a detailed history, with a timeline. What was the previous level of memory, cognition, and functioning? Exactly how has it changed over time? (And how reliable are the informants?) It's like detective work. Then, a careful exploration of medical problems that can affect cognition in older adults. (I can't tell you how many older people become disoriented and delirious because of an infection, or some other medical condition.)

Then, a review of medications, including over-the-counter meds. So many are known to interact, and so many are known to affect cognition. Are they taking meds as prescribed? (Common scenario: an infection causes disorientation; then, the confused person gets their meds mixed up, or entirely forgets to take them. The confusion then worsens, sometimes dramatically.) And how much alcohol is on board? Has alcohol use stopped suddenly, causing withdrawal symptoms? We also check for mood disorders and other psychiatric conditions. Depression, anxiety, bipolar disorder - all can affect thinking and behavior.

And while exploring all this, I'm also considering the dreaded question: could it be dementia? Many families bring their elderly relatives to my office with that question. I have to be so patient, and so careful, when probing for this diagnosis. How frightening and painful for some, to hear a doctor ask, "Can you tell me the date?" - knowing the potential consequences of a wrong answer. It can be excruciating.

I can't speculate about anyone's condition, based on news reports and editorials. I hope that anyone who's showing signs of a troubling "mental status change" is talking to their doctor. These conditions tend to not improve with time. With the aging of the boomers, these issues will arise more frequently, and not just in political campaigns. But can voters demand that a senator (or any public official) reveal medical records, or undergo an evaluation and demonstrate competency? I'll be interested to see how events unfold in Kentucky.

Afterthought: "these conditions tend to not improve with time" alone. If it's delirium, and you find and treat the cause, things can get better. If it's dementia, there are things that can slow the decline. But "wait and see," without any intervention, tends to lead to more deterioration.
Sometimes people wait until there's a crisis. Then our phones really start to ring.

What do patients think...

about Brownlee's article, accusing psychiatrists of ignoring damaging evidence about antidepressants? I'm bracing myself for their questions. Curiously, there is little reaction so far. But I am full of questions for them. What is your opinion of your treatment? What do you think about your meds? Have you felt comfortable asking questions about your treatment?
So far, there is more interest in talking about current issues, and about what's going on in their lives. There seems to be some acceptance of the ambiguities and unknowns of psychiatry. (If they weren't accepting it, they might not be making appointments.) One said, I know what happens to me if I don't take the meds, and I don't want that to happen again.
That is where we often find ourselves in psychiatry. I've been asked, why can't medicine be based on science? We think we are as scientific as we can be, but to one reader, that's not enough. How can we ask even one patient to take a drug that still has unknown physiologic mechanisms? All we are left with is current research (it will help when we are allowed to see negative studies). We're always trying to interpret the research, with all its limitations, and communicate the results to patients.
And yes, to another e-mailer, I wish that we psychiatrists knew more about what we are doing. No one will be happier when we have better understanding of the mind, and when current treatments have been replaced by more effective, less risky options...

Housekeeping chores....

In an effort to keep grafitti off the site, "comments" have been disabled. I have an e-mail address now, and in my continuing quest for extreme confidentiality, the account thinks that my first name is "shrink" and my last name is "ette." The address is now: shrinkette01, immediately followed by @earthlink.net.

Also I see that photos are lighter on my Mac than on PC's...drastically so. So I took down my photos of Diamond Peak etc - you can't even see the trees! - and I'll have to doctor them up in Photoshop.

Gotta get this blog into shape....Grand Rounds is coming here in November!

Mental health break, revisited

Three Sisters Wilderness, 90 minutes east of Eugene, Oregon.

(click photo to enlarge)

Near Cougar Reservoir

Three Sisters Wilderness, Oregon

(click photo to enlarge)

Is Diamond Peak still there? Yes...

Photo taken next to Highway 58, standing on a picnic table.

(click photo to enlarge)

Psychiatric mudslinging in the presidential campaign, part two

Instapundit cites the Drudge Report, quoting John Edwards on ABC News Nightline: "...if you live in the United States of America and you vote for George Bush, you've lost your mind."

When I started this blog, I wanted to comment on psychiatric-tinged insults that people were flinging at public figures: "crazy," "barking mad," and so forth. (See here, and here.) I've pleaded for restraint. These terms are hurtful to our patients, and perpetuate stereotypes and stigma. Now they're flowing in the opposite direction, from candidate to the public. I've never heard a candidate refer to American voters in such terms. (Has anyone else?)

No doubt, he wanted to convey that a vote for Bush is irrational, or incomprehensible. But using terms like "lost your mind" adds nothing to the debate. It will anger all Bush voters (regardless of whether or not they are models of mental health). Why use phrases that make suffering people and their families cringe?
The mentally ill have enough to deal with, and few enough people to speak up for them. Again, I plead for some thought and compassion. A vote for your opponent may be illogical or unwise, it may surpasseth understanding. But please don't use the language of stigma, making accusations about opponents' sanity. Thank you.

Afterthought: Mental health and unhealth have no allegiance to any political party. They are distributed across the political spectrum. All candidates might be surprised by the thought processes of some of their supporters...

WebMD explores pro-anorexia websites...

...which are written by anorexics, for anorexics. Their goal is not recovery. They have tips for maintaining an eating disorder, and they denounce treatment. It is entirely possible that they are spreading the illness and providing an online "support system" for continuing life-threatening behaviors.

I was ready with a post, plus link to WebMD's article, when I ran across a statement: "Did you know that linking to our site, except for our home page, is illegal?" Yikes - I've already linked to one of their articles, about patients lying to the doctor. I had no idea that I needed to ask for permission. What to do?

I decided that I would like to be able to link to them in the future, and I would like to stay on their good side (even though they probably have no inkling about my use of their article). I removed the post with the illegal link, and sent them an e-mail, asking them for mercy. Then I filled out their online permission slip. Am I the only one on earth who does this? I did hear back from them via e-mail. They were extremely nice, and they are glad that I am trying to remedy the problem. But...I still don't have permission to link to specific articles from their "My WebMD News" site. I need to be more careful about my links.

Update: Thanks to the anonymous commenter, who says that courts have upheld the right to the kind of linking that I'd like to do. When I review the terms and conditions on the WebMD site, it seems that WebMD has a different take on this. Until I hear from them, I encourage people to link to their home page and read the article (it's easy to find, it's in the "WebMD News Center" part of the site.) How many diseases have their own online advocates that teach people how to be ill, and discourage treatment? The social pressures that affect eating disorders can now be magnified and extended online. There's a risk that, by pointing out these sites, I might be showing anorexics a way to stay sick. I hope that risk is outweighed by physicians' need to know about what patients are reading.

The psychology of Spongebob

If the children in your life watch cable TV, chances are that you know "who lives in a pineapple under the sea." When Spongebob Squarepants premiered on Nickelodeon in 1999, it was hailed for clever animation, wild humor, and smart cultural references. But Spongebob also visits psychological terrain, with more sophistication than most cartoon fare. Guilt, obsessions, histrionics, paranoia, rage, hallucinations - all may be found in the Spongebob oeuvre. Watch longer, as the characters bounce in and out of trouble, and themes emerge: Spongebob is about naivete, and the loss of naivete. It is about growing up, and the loss of illusions. It is about learning how to live in the world without the shelter of one's parents.

Spongebob is youthful, eager, fun-loving, and completely trusting. Each episode presents him with a lesson about the world. He finds fun and friendship, but he is also exploited. He meets rejection, or treachery, or cruelty. He finds failure or success, acclaim or ridicule; loss, or illness, or death. Sometimes the lesson is not learned, and he remains as blissfully naive as ever. When he does gain an insight, however, his knowledge is short-lived. In the next episode, the clock is always turned back; he starts afresh, and he is as naive as when we first met him. He repeats the cycle, like a cheerful Sisyphus, eager to push the boulder up the mountain again.

Parents are a distant presence in the cartoon. Moving back home with one's parents is to be regretted and resisted. His boss, Mr. Krabs, is a paternal figure who offers protection and advice. But the boss is so consumed by greed that his advice is often suspect. Friends, not family, play essential supporting roles. The lone, strong female character, the squirrel Sandy Cheeks, has brains, athletic prowess, and common sense. But she clearly descends from a distant world, quite mysterious to Spongebob. Older figures in the cartoon - except for Grandma - are portrayed in humorous but dismayingly unsentimental terms. Spongebob, true to form, romanticizes the wisdom of old age, even as the cartoon skewers it.

The centrality of boss and peers; the focus on independence and competence; the mystery of the opposite sex; the endless conflict between Spongebob's idealism and the world he encounters - these elements open a window to themes of older childhood, adolescence and young adulthood. When Spongebob's movie premieres this fall, I will be watching for the evolution of his character. Will his enthusiasm and idealism triumph? I'm ready, I'm ready, I'm ready to find out.

Still recovering

It's post-op day 2 here. Mike has sutures, staples, dressings, meds, side effects, and a drain. But he's stronger and his facial nerve is intact (for which, we are most grateful.) Yesterday he felt like a "squashed slug." He said, with wonder, "I always thought that I would fear death more than illness. But right after the surgery, I thought, 'death has to be better than this...'" Mercifully, that feeling was brief.

A few things caught my eye while he was napping. New York Magazine has a terrifying article about teens popping prescription meds, including antidepressants, tranquilizers, and stimulants.
Older adults, meanwhile, are skimping on their meds because they can't afford them. They are also sharing meds with friends and family who can't afford (or run out of) meds. Sometimes when we need to switch meds, they ask, "Can I first use up the ones I already bought, and then try the new ones?" We are advised to inquire more closely about what exactly is happening to the pills we prescribe.
In caffeine news, it looks like caffeine withdrawal may be classified as a mental disorder. (We were proud that we had stopped drinking coffee, until we noticed that we had 5 teabags in our cup...)

I caught part of the first Bush-Kerry debate on a tiny TV, while finishing paperwork in my office. Kerry's voice was firm, deep, and you could follow it on a keyboard: notes descending, "That's wrong." "I think that's wrong." Bush's voice was higher pitched, with more pauses, more groping for words, and more repetition of phrases; no authoritative bass tones. The critics of "gender imagery" should be silenced for awhile.

Thanks to Blogborygmi...

...for including one of my posts in Grand Rounds. (It didn't bring any perks around here; most of my colleagues asked, "What's a blog?") I'm sure that more docs will be encouraged to start their own blogs...Just watching the sitemeter is a thrill. (Look! there's someone from Australia! And...Ireland!) It's brought at least one new reader who isn't pleased with the registration process for making a comment. My settings say that anyone can comment, not just registered users. I'll try to find out what Google is doing.

Meanwhile, life is demanding more from the shrinkette household. My husband had surgery today, for a parotid gland tumor. (It's benign but it had to come out, or it would grow large and cause nerve damage.) I'm trying to be supportive. While the hospital staff was terrific, and the care was quite personalized and attentive, I know that I can't generalize about our experience, because I've worked at this hospital for seven years. This hospital is like family. (I can only imagine what it's like for patients who don't have that connection.)

It was a big surgery. Six hours post-op, Mike feels awful, but it looks like there were no complications. Blogging will be sporadic for awhile...