The next Grand Rounds...

is at Dr. Rangel's blog.

Accepting submissions for the next Grand Rounds - Deadline is 9 pm mountain standard time (GMT-7) on 1-3-2005. Send submissions to drrangel - at - swbell.net

Even though the deadline is 9 pm I will still be checking my email into Tuesday morning and will try and add on late entries however you have the best chance of being read if you get in your submission early. Submit early. Submit often!

I will try and group the entries into categories. Nick from Blogborygmi came up with some general guidelines for the first Grand Rounds but these are guidelines only and may help you in getting ideas about what to write about.

According to Nick, the first post listed in Grand Rounds typically gets the most attention so I have decided to revive Kevin MD's idea of choosing an Editor's pick from among the submissions to be the first listed in Ground Rounds. This pick will most likely be that submission that has the most original material and/or a well written opinion and will not necessarily be a patient story or case study nor the longest article.

New feature: Why should Grand Rounds be limited to bloggers? For those readers who have no forum on which to voice an opinion I am offering to post their submissions on RangelMD.com as a guest contributor and have them listed on the next Grand Rounds.
posted by Chris Rangel MD 12/30/2004

Hope for the new year

Hand to S. E. Asia, originally uploaded by Le Cactus.

A rock star of psychiatry

Dr. Robert Spitzer, father of DSM3, is profiled in the current New Yorker. Most of my residency was spent memorizing his work, and trying to apply it in the clinic. Funny thing...the author makes connections between Dr. Spitzer's personality and his contributions to the field. Both are described as rather concrete, and lacking in emotional awareness. Does it all seem a bit facile?

I do admire his work. I can't imagine practicing without it. But the article states that we have endowed the DSM with authority that it doesn't quite deserve. These diagnoses really were banged out in committee. Sometimes the loudest voice prevailed.

The product of this committee work - "all in favor of the criteria for post-traumatic stress, say aye" (especially if the man in charge agrees) - organizes our thinking, when we make diagnoses and select treatments. It will always be a work in progress, and we need to be clear about that when we work with patients. (One of my most-repeated lines: "In the year 2004, this is how psychiatrists in America would diagnose your condition, based on these criteria.") One benefit of the DSM3: it enabled us to define groups of patients that we could study, and see if any of our diagnoses and treatments were helpful.

The article says that patients don't tend to challenge DSM diagnoses. The author must not be from around here! Almost everyone challenges us about everything, as well they should.

True story: I talked to Dr. Spitzer once. Really! I was a new intern, starting out. I was looking for a questionnaire that was cited in a journal. My search was going nowhere. I decided to phone the author of the article and ask him about it. "Hello...Is Dr. Spitzer there?"

Senior residents heard me and started to panic. "Do you know who you're talking to??!" they hissed. I had no idea, really, but as the pandemonium grew, it started to dawn on me. It was as though I had dialed the White House and asked to talk to the president.

But he was very nice to me. He explained the reference, and gave some pointers on how to find it. I had spoken with the rock star of psychiatry! (No glamour rubbed off on me, though...)

It's too bad I was so clueless that day. If I could talk to him today, I would have so many questions. Then again, only the greenest of interns would have called him in the first place.

Who's stingy?

Dr. Daniel Drezner analyzes the "stinginess" meme:

Is the United States stingy with disaster relief? Compared to other OECD countries, no.

President Bush was correct in pointing out that the U.S. is the largest provider of "humanitarian relief aid" in terms of total dollars -- in 2003, the U.S. gave $2.478 billion (all figures courtesy of CGD's David Roodman, who plucked them from the OECD's Development Assistance Committee).

Of course, the United States is also the biggest economy, so the raw dollar term doesn't mean that much. What about in per capita terms?

...Out of the 21 major donors, we're ninth -- hardly stingy, though not the most generous. One could make the case that comparing large economies with Scandanavia or the Benelux states is unfair, because the bigger economies have other public goods functions to fulfill. If you limit the comparison to the G-7 countries, only Great Britain is more generous....

[C'mon, though, just...$35 million pledged for tsunami relief efforts in the first few days?--ed. Well, that figure probably doesn't include the cost of military deployments or the dispatching of U.S. CDC personnel to the region. That said, here's the relevant graf from Jim VandeHei and Robin Wright's Washington Post story:

The usual U.S. contribution during major disasters is 25 to 33 percent of total international aid, according to J. Brian Atwood, a former USAID administrator. So far, the U.S. contribution is 13 percent of the $270 million in international aid that has been pledged, the United Nations said Wednesday.

My guess is that the U.S. will ramp up its contribution as regional needs are properly assessed. At a gut level, however, $35 million sounds puny compared to the devastation in the region. Combine this with reporters eager to feed the "Bush administration does not play well with others in world politics" meme and you've got a lovely political football. Of course, the initial comment by the United Nations official also fed right into the conservative meme about the UN being reflexively anti-American...

I've been watching the emotional tone of the debate, as we work through the problem of "who's doing their fair share." Guilt, mistrust, anger, rationalization, and wounded pride are evident. (I'm not the first to wonder if the UN is shaming us into giving more.)

But can't we be proud of this news from the American Red Cross?

-Five American Red Cross workers currently in or en-route to affected areas (Sri Lanka, Maldives, Indonesia) with expertise to support relief effort in three primary areas: water sanitation services, family linking and reunification, and relief supply distribution.
-Relief supplies—including plastic sheeting, family size tents and hygiene kits—housed in area near region to ensure quick mobilization, ready for shipment and distribution.
-As of noon 12/30/04 donations to the American Red Cross International Response Fund (IRF) stand at $27.9 million.-American Red Cross leadership will continue to work with the International Federation of Red Cross and Red Crescent, its sister societies and other international partners in the coming days and weeks on this expansive international relief effort.

Personally, I'm with on Arcanus Maximus on this: "I love watching stingy Americans donate via Amazon.com." (See link in sidebar!)

For tsunami victims, part two

Excuse me, did I hear correctly - that a UN official is calling Americans "stingy" for not giving enough foreign aid? Coming on the heels of the oil-for-palaces scandal, this seems a bit rich.

But we will show him, friends, won't we? Even though we are buried in debt up to our earlobes and beyond, we will open our wallets for this horrifying crisis, because it is the right thing to do.

There is a "Carnival of the Charities" (sort of) at the Command Post, which is continuously updated - an excellent resource (thanks, Medpundit). I did my own tour of a few sites, with my debit card, last night.

Most satisfying overall was World Vision, which gives you a shopping experience: $25 dollars for one Family Emergency Package, how many would you like today? Other good sites were American Red Cross, Oxfam America, and Canadian Red Cross, which allow you to target your donations to tsunami victims.

More worrisome was the ICRC, which does have a presence in the region and is active there now, but does not specifically mention the tsunami (as of last night, they didn't). They have a category for giving "where need is most urgent," which makes me wonder if I'm buying the chairman lunch. No, banish that stingy thought! I forked it over for them, too. (I'm confused about the Red Cross hierarchy - the Committee, the Federation, the national organizations...)

I'm a little wary of some charities, ever since I sponsored a girl in Africa. The letters trailed off after awhile, but I didn't mind. I figured she was busy. I kept sending dough. Then, I got a letter from their mortified chief, who said that the girl had run off a few years back, and they were sorry that they hadn't told me. I was miffed for awhile, but I realized that my donations were probably still doing some good. And that was the point, wasn't it?

Stingy, indeed. Right now, my sitemeter is in a frenzy, with all the people googling "tsunami victims relief" and landing on my post. Well, we'll see who's stingy, won't we?

Update: CNN is reporting that the UN official has retracted his statement. He was "misinterpreted."

Another update: This is one of the easiest ways to donate. Give to the Red Cross, on Amazon. Watch your gift increase the total collected. (I'm trying to put this in my sidebar...)

The twenty days of Grand Rounds

Geena does a stellar job with Grand Rounds this week, at Codeblog!

Health news "highlights" of 2004...

from Dave Barry's "Year in Review:"

...On the health front, the big story is a nationwide shortage of flu vaccine, caused by the fact that apparently all the flu vaccine in the world is manufactured by some guy in Wales or someplace with a Bunsen burner. Congress, acting with unusual swiftness, calls on young, healthy Americans to forego getting flu shots this year so that more vaccine will be available for members of Congress.

President Bush notes that additional vaccine "could be hidden somewhere in Iraq..."

...Meanwhile, the condition of Yasser Arafat, already worse than anybody believed possible, somehow worsens still more, until it becomes so bad that Arafat no longer responds to a medical procedure known technically as the Hatpin Test, at which point he is declared legally deceased. After a funeral service attended by a large and extremely enthusiastic crowd, he is buried in several locations...

... the pro-baseball world is stunned by the unbelievably shocking and astounding and totally unexpected news that some players may have taken steroids. "Gosh," exclaims baseball commissioner Bud "Bud" Selig, "this could explain why so many players suddenly develop 200 additional pounds of pure muscle and, in some cases, a tail." Seeking to restore fan confidence in the sport, the players' union and the team owners, in a rare display of cooperation, agree that it will be necessary to raise ticket prices.

All this, and more (hat tip, Sullivan).

The next Grand Rounds...

is at Codeblog. Deadline is Monday, December 27, 9:00 PM EST. Send in your favorite medblogging!

For tsunami victims

Send online donations to the International Committee of the Red Cross here, and donate to Care International here.

Update: Some more choices for giving. The American Red Cross has an International Response Fund, which includes aid for tsunami victims:

"You can help those affected by the recent tsunamis in South Asia, the humanitarian crisis in Sudan and Chad, and countless other crises around the world each year by making a financial gift to the American Red Cross." Donate here. (Select International Response Fund from the menu.)

Also, the Canadian Red Cross has sent out an urgent appeal for cash donations for victims of flooding in Asia. Donate here (Select "South East Asia Tidal wave and Earthquake" from the menu).

Another update! Hugh Hewitt has recommended World Vision for excellent disaster relief for tsunami victims. I make no claims about any of these organizations, but I'd just like to do something...

Note - yet more discussion of aid, and aid links, by Instapundit, Jay Manifold, Chanakya, Tim Blair, and the Command Post.

12/27 update: The Christian Science Monitor describes relief efforts, and mentions the International Committee of the Red Cross, Care International, and World Vision.
They provide more links to aid agencies, via an AP source.

On stigma and the mentally ill

At Blogborygmi, a med student gets a lesson about stigma from a cabdriver.

And Medscape interviews Dr. Patrick Corrigan, PsyD, about stigmatization of the mentally ill.

Medscape: What are effective ways to combat stigma?

Dr. Corrigan: Looking at public stigma, we've broken down change mechanisms into 3 -- education, contact, and protest. Protest is usually a "shame-on-you" kind of statement and an appeal to stop thinking that way. As an attitude changer, protest tends to give you a rebound effect. Research shows that attitudes get worse. Behavior, on the other hand, might see some benefit.

One example is a show on ABC called Wonderland. In the first episode, which aired on March 30, 2000, a person with mental illness shot 5 people and stabbed a pregnant woman in the abdomen. Lots of advocacy groups came out and said, "We're not going to put up with this grossly stigmatizing image." ABC thought this was great because it got them a lot of press, but then the advocacy groups went to the sponsors and ABC eventually pulled the show off the air.

Medscape: In your paper, you focus on contact.

Dr. Corrigan: Let's talk about education first, which is transposing the myths of mental illness with facts. Education is popular because it's exportable -- you can package it up and send it around, such as public service announcements on TV. Unfortunately, the effects of education are small and tend to wash out altogether in a week or two.

Contact is introducing people with mental illness to the rest of the population, and usually that leads to a decrease in stigma. We've done a couple of studies on it. In 2 studies, we compared contact with education, and contact led to significant changes in attitudes and behavior that were maintained until a month later.

We did a study in which we randomly assigned college students to 1 of 3 groups in which they had contact with either a live or videotaped person with mental illness.[3] One we called high contact, which would be meeting a person who would greatly challenge the stereotypes of people with mental illness. An example would be a famous person coming out of the closet, such as Mike Wallace or Patty Duke. A second type would be low contact. This would be people who greatly mirror the stereotype of mental illness, such as a person who's homeless. The third group is in the middle, someone struggling with mental illness who, despite that, is living on their own with a full-time job.

We measured attitudes precontact, postcontact, and at follow-up, and found that low contact does not work very well -- meeting a homeless person on the street does not challenge a stereotype; if anything, it reinforces it. High contact -- knowing about famous people -- did not tend to have a big effect.

What tends to work most is the middle group, when you find out a coworker or person in your church or a neighbor is struggling with a mental illness. That tends to greatly challenge the stereotypes.

A Christmas wish

Last night, as you know from the last post, Santa stopped by our house for refueling. Before he left, he asked me what I wanted for Christmas. Without hesitating, I replied, "World peace. Right now. Today."

He grimaced. "You and the whole world, this year...well, I'm working on it. Isn't there anything else?

"For me? My wish?" I took a deep breath. "I wish patients would stop calling me by my first name."

He grinned. "What's wrong? Don't you like that?"

"I hate it. I can hardly stand it."

"Why, they're just trying to connect with you as a person, aren't they? Instead of that doctor role."

I groaned. "They think that's what they're doing, but they can't. It doesn't work. I'm not dealing with them as a person, I have to be the doctor. Calling me by my first name doesn't change that. It makes my job harder."

He stopped laughing and sat down. "Maybe you'd better tell me about it," he said.

"The hardest are the ones that call me by my first name as soon as they meet me, and then every three words after that. 'Shrinkette, you know, Shrinkette, that my problem, Shrinkette, all started, Shrinkette, when I was three, Shrinkette...' By the fourth "Shrinkette," I don't even hear any other word they say. I want you to change my name to 'Doctor.' Make it, 'Dr. M. D. Doctor, MD.' That will look good on my name tag."

Santa eyed me carefully. "You think they're playing a game with you."

"Yes!"

"...and you think they're not respecting you...your hard work, your identity, your authority. It's a narcissistic injury for you. And you need to have professional boundaries with your patients."

He's good, I thought. "How did you know all that?"

"Ho-ho-ho! For years, I've delivered gifts at the Institute for Psychoanalysis, and they keep me informed." He turned to leave.

"All right, Shrinkette...I mean, Doctor Shrinkette...I won't be able to make them stop. But you will understand them better, and it won't get on your nerves so much. You will know what they are doing, and why they are doing it, and why it bothers you. You will still be the doctor, no matter what they call you. Ho-ho-ho! Merry Christmas!"

Thanks, Santa...let's see how it goes at work, now.

Pay-for-performance is coming to town

Santa took a break at our house last night. Midwestern snowstorms had put strain on his reindeer. They napped on our forested lot, while Santa and I had a fireside chat. I wanted to know what people were asking for this year.

"Lots of requests about healthcare," he said, eyeing a plateful of cookies. "People asked me for harmless meds. All benefits, no risks. Had to disappoint a lot of folks. And requests for cheaper meds, better cures, the usual.

"But the biggest surprise? There were requests - more like demands, really - for doctors and hospitals to show that they are competent, and use proven treatments, or face consequences. Ho-ho-ho! Let's have some more eggnog."

Doctors proving their competence, or facing consequences? But, Santa...there are so many variables among patients, and so many different opinions about what should be done. The standard of care is so broad - it ranges from the most superior care you can give, to the average, reasonably expected care. How can our performance be measured and compared?

"Mark my words. The time will come when even psychiatrists will have to show that patients with 'a, b, and c' symptoms are getting 'x, y, and z' treatments. Just look at what they're doing already, with other specialties. Look at pneumonia vaccines."

What pneumonia vaccines?

"Hospitals are pulling out bells and whistles for acutely ill pneumonia patients, but they send vulnerable patients home without the vaccine. When word leaked out, it became a scandal. Now they'll be holding feet to the fire if the vaccine isn't given. It's in today's New York Times.

"Vaccines are just the beginning. Pay-for-performance is on its way, for doctors and hospitals. They're making a list, checking it twice." He downed his second cup of eggnog.

But Santa...why are hospitals taking the rap? Vaccines are part of good outpatient care. And what about patients who refuse to see their PCP's for preventive care, or who refuse the vaccines? Shouldn't patients share some accountability? And how do we know that those patients are giving informed consent for their vaccines?

"Ho-ho-ho! You'll have to ask Medpundit that one...let's see, she's next on my list... but the juggernaut is rolling, take it from me. Doctors will have to be very publicly accountable for specific things. Ho-ho!"

He climbed back into his jolly sleigh and flew away. Is he right? Will my "performance" be measured and rated, according to clinical guidelines? Santa seems to know what he's talking about. I'd better get my list ready for next year. I'll be asking for some wisdom, to figure out what's being asked of me in coming years.

The Meaning of Christmas

From the Llama Butchers (hat tip to Glittering Eye).
Although it is generally silly to speak of transcendence and cartoons, I've always felt that there was one very important exception to this rule, namely, Linus' recitation of Luke 2:8-14 in "A Charlie Brown Christmas". Even as a kid, I recognized that there was something very special about the moment when Linus walks out to the front of the stage, the lights go dim around him, everything is hush and he begins to speak in calm, measured tones:
And there were in the same country shepherds abiding in the field, keeping watch over their flock by night.

And, lo, the angel of the Lord came upon them, and the glory of the Lord shone round about them: and they were sore afraid.

And the angel said unto them, Fear not: for, behold, I bring you good tidings of great joy, which shall be to all people.

For unto you is born this day in the city of David a Saviour, which is Christ the Lord.

And this shall be a sign unto you; Ye shall find the babe wrapped in swaddling clothes, lying in a manger.

And suddenly there was with the angel a multitude of the heavenly host praising God, and saying,

Glory to God in the highest, and on earth peace, good will toward men.

As ridiculous as it may sound, just reading these words causes me to start tearing up. And Linus is absolutely right: This is the true meaning of Christmas.

I sometimes used to wonder how it was that in the midst of a rather poorly animated cartoon voiced over by a gang of child actors this moment could have come off as perfectly as it does, suddenly passing beyond the limits of the medium and touching on the greatest of glories. But it occured to me that the answer is really quite simple: Because Charles Schultz believed in what Linus said. I do, too. Glory to God in the highest, and on earth peace, good will toward men.

On that note, I wish to express my warmest wishes for the season to all of you who drop by our little piece of silliness, whether you're regular readers or just passing through. I'm sure plenty of you follow different faiths than I do, or may not even have a faith. That's okay. The message of Christmas on earth is not confined to a select group of believers but, as the man says, extends to everyone.

Merry Christmas and God bless you all, every one!

Encouraging news about Alzheimer's

Holly VanScoy, of HealthDay, interviews Alzheimers researchers. They're hopeful that recent breakthroughs will clarify mechanisms of the disease, and lead to more effective treatments.

Dr. Sam Gandy, vice chair of the National Medical and Scientific Advisory Council of the Alzheimer's Association and director of the Farber Institute for Neurology at Thomas Jefferson University in Philadelphia, agrees the next five to 10 years are likely to bring significant advances in both diagnosis and treatment of this presently irreversible condition.

Gandy is among the researchers who see the key to Alzheimer's may lie with the diagnosis and treatment of plaques and other abnormal protein aggregates called "tangles" in the brain, which many scientists think might be the hallmarks of Alzheimer's. The main component of plaques, a toxic protein fragment called beta-amyloid, is a primary suspect in the death of brain cells, which causes the mental deterioration that marks the condition.

He cites a breakthrough by Dr. William E. Klunk and his colleagues at the University of Pittsburgh. They recently developed a compound known as Pittsburgh Compound-B (PIB) that sticks to amyloid plaques and makes them visible on positron emission tomography (PET) scans for the first time. According to Gandy, the ability to finally view, monitor and measure amyloid probably heralds the beginning of a new chapter in Alzheimer's research.

"Combined with advances in medications to rid the brain of amyloid plaques, this could very well result in a major breakthrough in our understanding of and successful treatment of Alzheimer's," Gandy said. "It will not only answer questions about how amyloid damages brain cells, but it will help us monitor whether and how well the new medications work."

According to Gandy, as PET technology becomes more widespread, it will be increasingly possible to test the hypothesis that amyloid is the primary culprit in Alzheimer's.

"Our inability to visualize or measure amyloid in the brain was a huge bottleneck for research," Gandy explained. "Now that there are both medications that can rid the brain of amyloid and a method of visually monitoring the amount of amyloid present and the effect of the medication on it, we're about to move past that bottleneck once and for all. We should know very soon whether amyloid is the right target or whether our focus on it has been a huge mistake."

And what's this...lifestyle factors appear to play a role in prevention:

"...It's become clear that lifestyle factors that are bad for the heart are also bad for the brain. Cholesterol, obesity, diabetes -- these take their toll on the brain. Living a healthy, mentally and physically active lifestyle turns out to be a fairly good way to protect brain cells and, potentially, prevent Alzheimer's."

Murder on a psych ward

France is reeling from the brutal murder of two night-shift nurses, whose mutilated bodies were discovered on a psychiatric ward:

A savage double murder in the psychiatric wing of a French hospital, in which a nurse's decapitated head was left on top of a television in the patients' day room, stunned France and left hospital staff terrified of returning to work.
Staff at the 460-bed Pyrenees Hospital Centre near the south-western town of Pau discovered the bodies of two nurses - both in their 40s, and mothers of young children - at 6.45am on Saturday, police said.

One had been stabbed and slashed several times in the body, neck and throat, and was lying in a corridor in a pool of blood. The beheaded body of the second was lying at the foot of a fire door.

"It is horror, terror, fear, disgust - fear of returning to work," Cathy Sanders, a regional official from Worker's Front union, told RTL radio." (from the Guardian.)

The killings have sparked an anguished debate about security in French psychiatric facilities, as well as funding, staffing, and distribution of psychiatric services.

What would it take to start a national debate about those issues in this country? We've had our own problems with security, staffing, budget cuts, unaffordable medications, loss of community services, and wide variation in availability of psychiatric care. I think of the times I've felt vulnerable when working on a psych unit. When I know I'm walking into danger, I can summon security staff for a "show of force" before venturing into a room. But what about the unexpected dangers, the unpredictable intruders? And how much more vulnerable are night nurses in any setting? They may have less help, and longer waits for assistance in emergencies. Must we wait for a similar tragedy, before addressing our own safety?

Assessing the risks of meds

Dr. Maurice Bernstein responds to my post about Celebrex and drug safety. Dr. Bernstein writes the excellent Bioethics Discussion Blog. Here's his comment:

Just as relative benefits of drugs are displayed to the public in drug ads to get them to request from the physician one drug over another, it seems, unfortunately, that relative risk is presented to the public by the news media without providing understanding the statistical significance. Look..in a drug study, if two patients in a million patients who take the drug at this dose for this length of time gets a "heart attack" and only one patient in a million who were given an inert placebo gets a "heart attack" then the news media will report that there is TWO TIMES THE RISK of a "heart attack" in those who took the drug than those who took only a placebo. Where is the disclosure of the absolute risk which is two patients in a million compared with one patient in a million? Wouldn't the absolute risk be important to know if one is going to weigh the risk of taking or not taking the drug compared to the absolute benefit it may provide...such as 500 of 1000 patients taking the drug get complete relief of their chronic "aches and pains"? I think that the relative risk as reported is meaningless if the absolute risk is left unreported to the public. But I guess that is how it goes in news reporting.. get the "juicey" part out quickly or maybe I am too cynical. Somebody knows the absolute risks of the current COX 1 and COX 2 drug studies. Let's hear about those numbers. After all, full statistical disclosure makes good ethics...Maurice.

The need for confidentiality

I see that I have been described as "the psychiatrist who blogs about her patients." Again, I point out that every post has been altered and modified to protect confidentiality and disguise cases, such that it is not possible to determine who I am blogging about. (See disclaimer in sidebar.) Names, ages, genders, diagnoses, meds, dates seen in the clinic - all of this has been altered, or rendered so vaguely that no one's identity can be discovered.

The only unaltered info is contained in the e-mails that I receive from patients, for which I am so grateful. Even then, I edit these, and I don't publish names or e-mail addresses. I try to double-check to see if they really intended their e-mails to be posted, if they don't tell me up front that their e-mail is bloggable.

Of course, this means extra work for the physician blogger. It's easier to say, "Many patients say (this), or "Many patients do (that)." This may be the only way to post in those cases where altering every detail will make the post unintelligible. However, this sort of generalization can drain the life out of a post. I expect that I will be doing more of that type of blogging, from necessity. Patients have a right to expect confidentiality, and that's obviously more important than my blogging.

Is Celebrex next?

Medpundit thinks that the knives are out for Celebrex. I think she's probably right. Just last week, a patient's spouse told me darkly that his wife had suffered a heart attack and a stroke while taking Celebrex. The connection seemed obvious to him. Why were they seeing me? The spouse had apparently taken it upon himself to increase the patient's tricyclic, which someone had prescribed for sleep, until it had reached toxic levels. The patient was floridly delirious, hallucinating, agitated, uncontrollable. I told the spouse that the tricyclic was far more risky than Celebrex for the patient's heart. The spouse was most unhappy to hear this. I don't think I convinced him at all. (I can't imagine that the FDA would approve meds like the tricyclics if they were introduced today.)

If Celebrex goes, it will complicate pain management for most of my patients with chronic pain. This is a huge issue in Oregon, where medical licenses are revoked when doctors treat pain inadequately. My orthopedist friends tell me that their phones have not stopped ringing since Vioxx was pulled. Patients are terribly concerned. Derek Lowe, also cited by Medpundit, has offered some perspective in his post,"Safe, and other four letter words."

"Safe" is a word that means different things to different people at different times, which is something you'd think any adult would be able to understand. The only definition that everyone would recognize, at least in part, is "presenting no risk of any kind to anyone." That'll stand as a good trial-lawyer definition, at any rate.

And by that one, not one single drug sold today is safe. Of course they aren't. These compounds do things to your body - that's why you take them - and that's inherently risky...

The drug industry, the FDA, physicians and most patients recognize that safety standards vary depending on the severity of the disease. Toxic drug profiles are tolerated in oncology, for example, that would have stopped development of compounds in almost other area. And the standards go up as additional drugs enter a market - yes, I'm talking about those evil profit-spinning me-toos. One of the best ways to differentiate a new drug in a category is through a better safety profile.

So when someone asks, "Is drug X safe?", they're really asking a whole list of questions. What are the risks of taking the compound? That is, how severe are the side effects, and how often do they occur? How do those stack up against the benefits of the drug? Then you ask the same set of questions in each patient population for which you have distinguishable answers...

The COX-2 inhibitors look much better (in a risk-reward calculation) in the patients who cannot tolerate other anti-inflammatory drugs because of gastrointestinal problems. Vioxx itself also looks a lot more reasonable in patients who are not in the higher-risk cardiovascular categories. But it (and the others in its class) have been marketed and prescribed to all kinds of people, and the fallout is just starting...

Alzheimer's caregiving at Christmas

Holidays present special challenges for demented patients and their caregivers. Disrupted routines can cause unexpected agitation and unpredictable outbursts. Caregivers often feel pressured to carry on with Christmas as they have in the past, and it's hard to know what's realistic.

The Alzheimer's Association has practical advice for caregivers during the holidays:

Give yourself permission to do only what you can reasonably manage. No one can expect you to maintain every holiday tradition or event. If you've always invited 15-20 people to your home, consider inviting five for a simple meal...

Familiarize others with your situation by writing a letter that makes these points:

"I'm writing this letter to let you know how things are going at our house. While we're looking forward to your visit, we thought it might be helpful if you understood our current situation before you arrive.

"You may notice that ____ has changed since you last saw him/her. Among the changes you may notice are ____. I've enclosed a picture so you know how ____ looks now.

"Because ____sometimes has problems remembering and thinking clearly, his/her behavior is a little unpredictable. Please understand that ____ may not remember who you are and may confuse you with someone else. Please don't feel offended by this. He/she appreciates your being with us and so do I. Please treat ____ as you would any person. A warm smile and a gentle touch on ____'s shoulder or hand will be appreciated more than you know.

"I would ask that you call before you come to visit or when you're nearby so we can prepare for your arrival. Caregiving is a tough job, and I'm doing the very best I can. With your help and support, we can create a holiday memory that we'll treasure."

There is also advice about involving the person with Alzheimer's disease in holiday activities, and suggestions for gift-giving. More caregiving tips are available at the Alzheimers Association website, and at MayoClinic.com.

Holiday CPR Quiz

We renewed our basic CPR certification today. It's a requirement for all medical staff at the hospital. Psychiatrists endured the usual jokes, which are de rigueur ("How does your mannikin feel about choking?"). But I was inspired to make this CPR quiz. Do try to attend a CPR training course. You could save a life!
(See also my disclaimer.**)
1. You're opening presents by the tree. Grandpa is having chest pain...now he's unresponsive and doesn't seem to be breathing. What basic CPR steps are recommended? Answer: here.

2. Your family gathers to sing carols. "Joy to the world..." You notice your 6 year old niece, who has a history of heart problems, has suddenly become unresponsive. What do CPR guidelines suggest? Answer: here.

3. More horrors. The baby! The baby is not breathing, not responding. What is recommended by CPR guidelines? Answer: here.

4. Grandma chokes on Christmas dinner. What do CPR guidelines advise? Answer: here. And if the baby chokes? Answer: here.

5. Wait for it...now the dog is having cardiopulmonary difficulties. (Not required knowledge for medical staff, but the dog is sinking fast.) How does one help? Answer: here.

More CPR links, and info on basic CPR classes, here. Imagine, if you take this class, you will receive hands-on training to help save lives in each of these situations.

Thanks to Dr. Mickey Eisenberg, MD, PhD, who gives us Learn CPR, from which these links are taken. Here's what his site says about him:

Mickey S. Eisenberg, M.D., Ph.D., is a Professor of Medicine at the University of Washington and Director of the Emergency Medicine Service at the the University of Washington Medical Center. Dr. Eisenberg has taught and studied CPR for 20 years. He is actively involved in using innovative means (such as this web page) to teach CPR to as many people as possible. His wife, Jeanne, is a babe.

**(disclaimer: the above quiz is intended to familiarize others with information imparted in a basic CPR training course, and is not to be considered a substitute for an actual CPR training course. No medical advice is given on this site, except "Talk to your doctor," and in this one case, "Try to take a CPR training course.")

Reminder: the next Grand Rounds...

is at CodeBlueBlog. Deadline is Monday, December 20, 9 PM EST. Send him your favorite health-related posts!

Deck the halls 2

badkitty1, originally uploaded by shrinkette.

Our cat, taste-testing Christmas decorations.

Deck the halls

christmas1, originally uploaded by shrinkette.

Do these decorations seem strange when there's no snow on the ground? Snow is pretty rare in our part of Oregon.

Just wrapping presents and talking to friends and relatives today. Blogging to be resumed later...

Word of the day

...is "Woo-woo."

Usage: (adj.) alternative, new-age; when applied to treatment, often felt to be more interesting and promising than one's conventional therapy.

Example: "I'm doing Candelabra Therapy. They wave candelabras over the parts of your body with bad energy, like your knees. It's really woo-woo, but it works."

And: "I'm taking Cosmic Elixir. It's just dewdrops collected from the leaves of 12 endangered plants. It's really woo-woo but it helps."

Phrase of the day: from a patient with multiple tiny strokes. She says her brain scan looks like "the night sky, filled with stars."

The response we hope for...

This e-mailer calls herself "a success story of antidepressants." But the decision to take Zoloft wasn't easy for her:

...The night before I started taking the zoloft, I had second thoughts. I did more research on line and scared the hell out of myself reading about the specific side effects of zoloft. I talked with my husband and he thought I was crazy to take drugs since there was no way to really tell if I needed them. But I knew I needed to do something. I went ahead and took the pills and have been on it for 8 months. After 2 weeks I could tell a major difference...

Now Zoloft is not an easy fix. It does not solve all my life issues. I still struggle with with the same things I have always had to deal with. Life in general can be stressful...Sure, counseling may have helped me, but that counseler was not there when the waves of tears would come. He was not there when the anger came. You might say that it is all in my head and that a placebo may have worked, but I truly believe that my depression, anxiety and panic are physiological. And zoloft is a good solution for me.

Now my ultimate reason for my long explanation is to point out that antidepressents can do good. When people talk about the exessive use of something, the negative side effects, then I think it tends to lead people who can benefit away from that solution. No one should feel guilty for needing help. Just because something may be abused does not mean that it does not do any good.

Vertical Mattress, an orthopedic surgeon, joins our conversation about pitfalls in prescribing antidepressants.

Maurice Bernstein makes an interesting point about personal problems and predilections affecting our judgment. He said, "if that drug is working great for me, maybe it will be helpful for my patient." The flip side of Bernstein's statement is that, "well maybe if I have this disease [depression], and someone else seems to feel similarly, then they have the disease, too." From this you get widespread recognition of what seems like a totally new disease. New categories of illness are created and spread like wildfire. Culture and illness spread in nearly identical ways.
The "bias" towards diagnosis isn't so much an error in judgment as it is reasoning from relatively little evidence, something that surgeons and psychiatrists seem called on to do all the time. I have a long-standing frustration with the quality of much surgical research. My field of orthopedic surgery is no worse than any others, but most published articles in the major journals are still small series outlining new techniques. Most comparisons are underpowered to show even a large difference between two groups, meaning that, unless one of the treatments is so far better than the other as to be obvious, the study has no value. There's still a mentality of "I've seen this work so I'll do it." As long as the old dictum, "primum non nocere" holds, I guess this sort of tiny little scrap of evidence-based medicine will continue to have its place in our work."

So psychiatry isn't the only field with small, inconclusive studies! Dr. Bernstein cautions us about occasions when our reference point is ourselves. The situation described by V.M. can lead us to fall back more on our personal experiences. Many docs have left an examining room saying, "That patient sounds like me...that patient has what I have..." We're more than ready to offer anything that helped us. Dr. Bernstein's comments should remind us that when we sense that recognition, we should look harder, think harder, and think again. Have we really considered the possibilities? As Medrants says, "When diagnosing, keep an open mind..."

When doctors take antidepressants

Yet more e-mail from the blogging world, about a post on antidepressants.
Mr. Schuler writes,

If, as you've reported, 10% of American women are taking anti-depressants, it's a reasonable inference that the use of anti-depressants by female American physicians is substantially higher. What proportion are actually disclosing their use? My guess is very, very few. Self-policing of such things is a paradox. If one's judgment is impaired by medication doesn't this impairment apply to the decision to comply with laws requiring disclosure as well? And asking someone to put their own livelihood at risk is putting possibly unreasonable demands on people.

Self-prescription (or any of the several easy dodges around such things) compounds the problem.

I think the real need is a general cultural shift in the society at large and
physicians in particular against routine prescription of drugs for mood-
aleration in the absence of real clinical depression. The likelihoood of this right now isn't very high for reasons you've outlined.

Dave Schuler
The Glittering Eye
htp://www.theglitteringeye.com

I think the boards have weighed the risk of supporting sick doctors in getting treatment and possibly having problems with the treatment, vs. creating a situation in which sick doctors won't even consider treatment because of risks to their licensure. If you're a doctor in treatment, there is another doctor looking after you, and (one expects) watching you like a hawk for side effects (including behavioral side effects). The illness is more likely to impair judgment than the treatment.

I wish that one of Mr. Schuler's points could be shouted from the rooftops: these meds should never, ever be given casually or "routinely." Their ease of dosing has perhaps lulled doctors into a sense that they are easy to prescribe and monitor. And direct-to-consumer marketing may spread the idea among patients that these are not serious meds with serious side effects. Neither is the case.

And here's Dr. Maurice Bernstein, of the excellent Bioethics Discussion Blog:

Responding to your paging me.. "The focus is on competence, whether you're medicated or not. I'm interested in what others think about this. (Paging Dr. Maurice...) Of course, you are correct. What also troubles me is based on what you wrote.. "If a patient has stopped functioning, is unsafe, or is deteriorating because lack of appetite is causing malnutrition, we reach for these meds readily. Often it's not so clear-cut." OK..what if the treating physician is on mood altering drugs him/herself, might that not affect the therapeutic decision of that doctor with regard to the patient by explaining "if that drug is working great for me, maybe it will be helpful for my patient." A not so clear-cut patient illness is thus put on drugs. It is a given that all physicians should be aware that their own personal problems of any sort can affect judgment regarding patient care. ...Maurice. (You may publish this if you desire)

I agree. There can be subtle (or not-so-subtle) bias toward the use of these meds. This applies to doctors of all specialties (most antidepressants are prescribed by non-psychiatrists). And this also applies to other categories of meds, including tranquilizers, stimulants, and mood stabilizers. The difficulty in identifying this sort of problem with the meds is obvious.

Now seems like a good time to link to my post about resources for impaired physicians:
"Doctor, we have a problem..."

addendum - I didn't go far enough in my comments above. I don't know about Mr. Schuler's inference about the number of physicians taking mood-altering meds, and why it should be substantially higher, and that it's going unreported. I'm certainly not aware of any data about this. Antidepressants can affect mood, behavior, and judgment, but that does not mean they are necessarily placing patients at risk. I've watched the efforts of medical directors dealing with physicians who have perplexing behavior changes. There are many potential causes for such changes. These changes won't only be apparent at work. They affect multiple areas of a person's life, i.e. self-care, family relationships, driving, and so on. Are there enough safeguards? Mr. Schuler clearly doesn't think so. This issue extends far beyond complications of the use of antidepressants by physicians.

another update: The Rebel Doctor weighs in:

Being treated for mental illness or taking psyciatric medications is no longer career ending, but it will haunt a physician for the rest of his career. He will be asked about any history of psychiatric treatment on every residency/fellowship application, application for hospital staff privileges, and application for medical licensure. He will also be asked about it when applying for malpractice insurance. A doctor with a history of mental illness will have to disclose it for the rest of his career.

Reminder: the next Grand Rounds...

...is with Dr. Emer at Parallel Universes. His e-mail is emeritus followed by @gmail dot com. Deadline is Monday, December 13, at 9 PM EST. Send him your best!

"If only people would recognize their duty to end it all..."

Medpundit points to a Sunday Times interview with Baroness Mary Warnock, Britain's "philosopher queen." Her fireside chat with an awestruck reporter resulted in this headline: "Better for old to kill themselves than be a burden, says Warnock." After reading the interview, I think this headline is misleading, and that the Baroness would object. But it's clear that she thinks she, herself would rather die than be an unacceptable burden to her family. And she would understand if others felt that way too. Here are some quotes:

"In an interview with The Sunday Times, she said: 'I know I'm not really allowed to say it, but one of the things that would motivate me [to die] is I couldn't bear hanging on and being such a burden on people.
'In other contexts, sacrificing oneself for one's family would be considered good. I don't see what is so horrible about the motive of not wanting to be an increasing nuisance...'
"...(N)ot only does she now think assisted suicide should be legal...she also feels the very frail should slink away, like elephants, to die quietly. She reckons doctors, when asked to assist in this, bang on too much about their consciences rather than their patients’ interest.
"Oh, and she suggests that if parents want to keep premature babies with unviable lives life-support machines, they should stump up the cost. Gulp..."

I should probably give the Baroness the benefit of some doubt. This article has just appeared, and she hasn't had a chance to respond. But here are some more quotes:

“...'Maybe it has to come down to saying, ‘Okay, (non-viable babies) can stay alive but the family will have to pay for it.’ Otherwise it will be an awful drain on public resources.' But wouldn’t this offend against doctors’ desire to keep us alive? “I don’t see why the rest of us should be sacrificed to the scruples of the medical profession. Some say, ‘But we wouldn’t like to do it.’ Of course they wouldn’t like to do it, but maybe they should,' she intones with the cut-glass determination that sent young men off to do their duty in the trenches.
"Warnock suggests saving life for its own sake has become a fetish. She tells me of a gruesome story she heard from New York where a poor mother gave birth prematurely. 'Nurses were desperate to break a record (and save the baby). The over-effort was all sentimentality, really. The mother didn’t want the baby, she knew she couldn’t cope, and within days of going home it was found dead, eaten by rats.'

Note how her tone changes when she's asked if she would have helped her terminally-ill husband commit suicide.

"...Her husband, Geoffrey, was saved at the last from (a) gruesome death by what Mary considers a doctor’s mercy in upping his painkillers.
“He had, in the nicest possible way, been written off. He had an absolute horror of suffocation, of gradually being denied air and turning blue...

"The doctor’s actions saved him from that. If it had been necessary, would she personally have helped him into the night? She struggles to answer: 'Killing someone is very difficult. If I had been able to get hold of a tremendously large number of sleeping pills, I think I would have been prepared to put them in his reach. And if he’d had them I think he would have used them.'

I blog today in a state that has twice voted in favor of assisted suicide. The arguments for and against were complex. They dealt with patient autonomy and choice. We considered mental capacity to make decisions. We considered psychiatric factors contributing to hopelessness and suicide. We argued about inadequate pain control in end-of-life care, and measures to improve it. We discussed the value placed on living, suffering, and dying; the problem of defining a terminal condition; and the problem of determining when further attempts at cure are medically futile. And we were especially nervous about social pressures to kill oneself, once assisted suicide was legalized. These issues are barely considered in the interview. (There was no vote in Oregon concerning non-viable babies.)

When to finally say, "enough of treatment, enough of life?" The Baroness's answer boils down to this: when one feels like it, and when it's too expensive to do otherwise, and preferably if someone else takes responsibility for performing the troublesome part, like actually ending a life. Neither the interviewer nor the Baroness did justice to the issues. The Baroness has more explaining to do. These issues, I'm afraid, are more than a nuisance.

Dr. Charles spins a tale...

of an alarming headache.

Also noted: more from the Rebel Doctor on sleep apnea, and surgical options for treatment.

Gruntdoc has sound advice for ER patients everywhere.

Interested Participant, on problems with national health care in Australia. (He also submits posts to our Grand Rounds. Give him a vote!)

And Caltechgirl has a dazzling appeal for Spirit of America.

One more: this site is fun. "Fifty Optical Illusions and Visual Phenomena." (I'm afraid he may have another illusion...or misguided belief. He thinks we'll send him money for this...)

A patient comments on antidepressants

Some patients have responded to my post about the soaring use of antidepressants. We can't begin to comprehend what these illnesses and treatments are about, without listening to patients. (Thanks for writing, and for allowing me to share these e-mails.) One writes,
"I am 52 years old, mother of two (adopted) grown children, a nurse and a divorcee of 9 years. Looking back I realize that all my life with the exception of my work, where I have become very comfortable and confident, I have had what you might call a "just below the radar" tendency to anxiety and depression. I come by it honestly, (heh, as tho to have emotions is dishonest), many in my family have the same characteristics although for the most part, being of "sturdy stock" it was mostly swept away in the culture of "pull yourself up by the bootstraps". Not to dismiss this casually, in many instances it is the correct prescription. But what happens when major life events, a very unhappy marriage for instance, disrupts that brain chemistry that perhaps is a little vulnerable, and makes life miserable? My story:

"After a number of years of anguishing mental debate I finally came to the conclusion, with the help and validation of my feeling by my mom, I was able to see that divorce was the only viable solution in a marriage terminally wrong. The process was miserable, I was going to counseling and steadfastly refusing medication when it was suggested. I finally came to the conclusion that not only was I anxious and miserable in my personal life, working so hard to be supportive to my children, working out my own new role as a single mother, my work, which was the foundation of my being able to be independent and provide for my kids, was suffering. I was not able to concentrate in any of these roles, mom, nurse, etc. I was put on zoloft and the tumbling, circular thinking became linear and productive again, I was almost happy again. But..... always those buts...

"I didn't like being on medication. It was against my philsophy of self help, I was back on track, getting settled, I wanted off and so, while continuing some counseling, I quit taking the zoloft. For a while things were fine, I was functioning, the depression did not return and then I hit some snags, I was having difficulty to the point of depression and beyond, with a new relationship as well as relationships with both kids. More counseling, another "major depression" note in the chart and back on anti-depressants. (zoloft caused tremors, a bad thing in my line of work, I was put on effexor) Effexor helped very much, things straightened out, I continued to take it with some adjustments in dose (I felt my emotions were overly blunted) for several years.

"I leave out lots of details but the "end" of the story is this: For almost a year now I have been off medication despite the warning that " you've had two major episodes, the odds are that you will relapse". I keep an eye on myself. I recognize the beginnings of anxiety and acknowledge them, I work hard not to be fearful of those emotions, accept them as part of what I call "me". I use a technique taught by my counselor and ask myself these questions at the start of that "circular" anxiety feeling: when was the last time I slept well", how have I been eating?, can this problem wait until tomorrow?-- it works amazingly well. So far, so good. I'm the happiest I've been in years. I realize that I'm not wholly self sufficient, I need to ask for help sometimes, and may again need to do that.

"Some conclusions then: 1. yes, keep asking those questions every day, your patients need to assess themselves, its part of their growth 2. for many people meds alone are not going to work (see end of story above) they need the wisdom of counseling. "adjuvant therapy" as it were. 3. Lack of misery does not equal happiness--in the end you have to go beyond yourself, give of yourself, realize we're all in this together....happiness follows."

Another patient comments on antidepressants

"I was very interested in your post re the increased use of antidepressants. I was given them by what I consider an overzealous and impatient cardiologist. I was having dizzy spells almost two years ago and have a very low heart rate for someone of my size and build (average resting rate was then about 50 bpm, I'm 5 ft 7 and was at that time about 165 lbs). They ran a number of tests and all turned up negative for cardiac dysfunction. So, in his infinite wisdom, the cardiologist said I was having anxiety attacks (which I still dispute) and put me on Paxil.

"I hated it. I was on it for about 6 weeks, long enough to produce a clinical effect common to most people who are bipolar - I went through the roof. Then I went off it cold turkey on my own because of the side effects of Paxil, and I continued in a manic spiral until about three months later, after a quasi-psychotic episode (quasi, because I had a small dwindling pinpoint of insight that screamed STOP, and psychotic because I had a cold and clinical desire to see how much constant downward pressure it would take from a steak knife to sever my left hand), I ended up in hospital under a 72 hr involuntary commital, and ended up staying a week. I was officially diagnosed bipolar at that point. Prior to this, I was just a morass of confusion and pain, undiagnosed and living in mixed state hell for three months.

"The only benefit the knee jerk response of the introduction of Paxil did for me was that it made clear my illness as bipolar, NOT anxiety attacks or depression. It triggered a very dangerous episode and to this day I think he was wrong in prescribing such medication. I believe that antidepressants should be treated with the same care as antibiotics: our body chemistry changes with their introduction and unless we are confident (both patient and doctor) that any particular course of treatment is indeed suitable and beneficial for both (and not simply getting a patient out of your office and onto the next), then the treatment should be openly and honestly discussed - ramifications, reprecussions, everything. Then, as an informed team, the doctor and patient can decide on a treatment *together*."

The Doorknob Phenomenon

"Oh, by the way..." Medrants discusses the phenomenon of patients telling us a critical piece of information as they are literally walking out the door. Sometimes it's the main concern that motivated the visit. It immediately casts the whole assessment into a different light, and can make the correct diagnosis obvious (or wreck the diagnosis that you thought you'd already made).

Psychiatrists learn that words chosen in parting need special attention. New, significant topics might be first mentioned in the last few minutes, or as patients are reaching for their coats. Sometimes it's a bombshell. Sometimes patients have been struggling with a topic, and have been searching for a way to bring it up. It's called a resistance, and a defense mechanism, if the doorknob maneuver is used to avoid dealing with the issue. ("I should bring this up but I don't really want to get into it. There's no time to really talk about this now, right?") Shame and embarassment can contribute. Sometimes we have to wonder, is this a way to try to get more time and attention from the doctor?

During the visit, we're listening for what the patient says (and omits), the words chosen to say it, and the manner chosen to present it. We're taught to discuss "doorknob behavior" with patients, to probe doorknob issues. "I notice that last week you said something really important as you were just leaving. Can we explore that some more, right now?"

(update - of course, when the parting words are the first mention of domestic violence, as in the NYT article, then the doorknob is released, we sit again, and the next patient in the waiting room gets an apology. "Sorry, your doctor is running late." Now is a good time to have a nurse or a social worker available. More history is pursued, more details, and a safety plan is worked out. Then, more apologies to the next patient, who is waiting and wondering...)

Answers more easily felt than given

Whilst voting for Dr. Charles, I found this blog: "Thinking About Art." I've been discouraged by descriptions of the Turner competition, so I decided to search the blog for some insights. I found no references to "Prozac art" on the site. That's a relief. (I'm still not sure what "Prozac art" is.) There's an interesting comment thread on the site, asking "Who decides what is great art, and what is not?" I like this comment:

The value of art is like a glass of water. Minimal in a 4 star restaurant. Life giving in the desert. What do you need at the time...

Again, the importance of context.

That's partly what's frustrating about the Turner competition. I don't understand the context of the entries. The Guardian's description reminds me of Robert Benchley's piece about a "Sur-Realiste" painting that the French Academy refused to hang, ostensibly because "it didn't have enough paint on it." (In fact, he eerily presages the current crop of Turner entries.) Of the painting, he states,

"A great many people resent the fried egg in the upper left-hand corner. They claim that it looks too much like the sun. On the other hand, sun worshipers claim that it looks too much like a fried egg...The laughing snake in the lower left-hand corner (is) merely a representation of the spirit of laughing snakes, and has nothing to do with Reality..."
"The crux of the whole picture, however, lies in the fireman who holds the center of the stage. Here the artist has become almost photographic, even to the fire bell which is ringing in the background...As for the silk hat, the ladder, the rather unpleasant unattached face, and the arrow and target, they belong to another picture which got placed by mistake on top of this one when the paint was still wet. (The artist) feels rather upset about this, but hopes that you won't notice it."

Yes, parody is rather too easy. But some art almost begs for parody. How much are they actually self-parody? Of modern art, Gombrich asks, "(W)hat are these works meant to stand for? The answer is more easily felt than given, for such explanations so easily deteriorate into sham profundity or downright nonsense." Some Surrealists "were driven by their frantic wish to become childlike into the most astonishing antics of calculated silliness." Others consulted Freud for clues to the primitive mind. "The result may look monstrous to an outsider, but if he discards his prejudice and lets his fancy play, he may come to share the artist's strange dream..."

In this spirit, I will reconsider the Turner entries...and I invite anyone who's seen them to send their comments. Meanwhile, I'll stumble along with my pencils and paints...

The Rebel Doctor, on sleep apnea

...the obstructive kind.

(Sullivan, take note!)

Obstructive sleep apnea (OSA) is a disease characterized by episodes of complete or partial collapse of the upper airways during sleep. It has been estimated that 2-4% of the adult population has it. Symptoms of OSA include loud snoring, daytime sleepiness, and apneas (breathing pauses) witnessed by a bed partner. Risk factors for OSA include obesity, an abnormal jaw structure, and having a crowded oropharynx (the area around the tonsils).
OSA has long-term health risks, including hypertension.

The usual treatment for OSA in adults is continuous positive airway pressure (CPAP):
http://familydoctor.org/791.xml.

OSA is becoming increasingly more common in children. It used to be that most cases of OSA in children were due to adenotonsillar enlargement; the OSA could usually easily be cured by surgically removing the adenoids and tonsils. Now obesity is causing many cases of pediatric OSA and there are a lot of children on CPAP. This article http://news.bbc.co.uk/2/hi/health/4059357.stm discusses OSA in obese children.

OSA, in both adults and children, is usally diagnosed by an overnight polysomnogram (sleep study). Airflow, depth of sleep, and blood oxygen levels are closely monitored during a polysomnogram. Polysomnograms are a little different in children as compared to adults (for example, different criteria for measuring breathing pauses). Unfortunately, many sleep labs lack experience in diagnosing and treating childhood OSA.

If you suspect that you or a family member has OSA, you should discuss referral to an accredited sleep center with your primary care doctor. This site can help you find an accredited sleep center: http://www.aasmnet.org/listing.asp

Soaring antidepressant use, part two

People are responding to my post about the many uses of antidepressants in the clinic. Dave Schuler, of the Glittering Eye, asks:

1. Has the drug in question been approved for the use for which
the physician is prescribing it?

2. Does the drug in question have demonstrated efficacy for the
symptoms the physician is attempting to treat?

3. Has the drug been approved for the target population viz. children?

There are also larger moral and ethical questions WRT mood-altering drugs.
At what point do the effects on the emotions of the patient constitute
a removal of the patient from the human condition which includes
feeling pain and grief?

And a few more: should a physician who is taking mood-altering
drugs be required to refrain from surgery? Disclose the situation
to patients? Undergo greater supervision?

I've been working on his questions. The FDA's web site provides info (try here and here). According to Micromedex, here are FDA-approved and off-label uses of some antidepressants in adults. Note: Don't panic if your meds are off-label, or if your illness is not on this list. There may be studies showing that your med is helpful for your condition. Ask your doctor to explain why you are taking your medicine. (For definitions, check here and here.)

Prozac FDA approved: Depression, bulimia, obsessive-compulsive disorder, panic disorder, pre-menstrual dysphoric disorder. Off-label uses: Post traumatic stress disorder, Raynaud's syndrome, fibromyalgia, body dysmorphic disorder (which often has depressive and obsessive features)

Zoloft FDA approved uses: Depression, OCD, Panic disorder, PTSD, social anxiety disorder, pre-menstrual dysphoric disorder. Off-label uses: dysthymia. Possible indication for pediatric OCD.

Paxil FDA approved uses: Depression, OCD, social anxiety disorder, PTSD, generalized anxiety disorder, pre-menstrual dysphoric disorder. Off-label uses: pathological gambling.

Celexa FDA approved: Depression. Off-label uses: tension headache, panic disorder.

Lexapro FDA approved: Depression, generalized anxiety disorder. Off-label uses: "anxiety with depression."

Effexor FDA approved: Depression, generalized anxiety disorder, social anxiety disorder. Off-label uses: Pre-menstrual dysphoric disorder.

Wellbutrin FDA approved: Depression, smoking cessation.

If anyone sees errors in the above, please e-mail me. All of the listed meds have demonstrated a degree of efficacy that is considered significant, in clinical trials. Placebo rates in the studies do tend to be somewhat high. (Also problematic are the "side effects" reported with sugar pills, which can be greater than the reported side effects of the meds. Kind of a "reverse placebo effect." Some do feel worse on the placebo.) The most improvement occurs when you are doing more than just taking a pill...i.e., therapy.

I believe that only Prozac has been approved for children, but I defer to my child psychiatrist colleagues on this one, as the Zoloft-sellers have also been making hints about this. (Paging Dr. Baker!)

One of our greatest challenges is to determine when an antidepressant is indicated, and when people are seeking a "quick fix" for a condition that isn't really an illness. If a patient has stopped functioning, is unsafe, or is deteriorating because lack of appetite is causing malnutrition, we reach for these meds readily. Often it's not so clear-cut. The DSM helps.

Should doctors taking mood-altering drugs have more supervision and more disclosure? We're already required to disclose these things to medical boards, which then decide if we can be trusted with a license. We also have to disclose this info to managed care companies with whom we contract. The focus is on competence, whether you're medicated or not. I'm interested in what others think about this. (Paging Dr. Maurice...)

Grand Rounds 11 at Dr. Charles

...and he's done a fantastic job. Dr. Charles is a gifted writer. I believe that he'll be the first medblogger with a book contract!

Art as Prozac?

This just in, from the Guardian: Tim Lott, a columnist at the Evening Standard, thinks that "art nowadays seems to act 'as a kind of spiritual and even moral Prozac' and 'Prozac art is very well represented in the new Turner prize shortlist, which has a high self-cuddle factor.'"

This, in reference to the prestigious art competition held annually in Britain. Apparently they're also calling it "feel-good art." (What SSRI side effects accompany this art, do you think?)

Here is the Guardian's description of the winner of this year's prize. It is

"Deller's competition entry, which brought together brass bands, acid house music, a memorial to a north London cyclist killed by a reckless driver, and George Bush's favourite burger bar waitress. The only naked creatures were the 3m bats streaming from the mouth of a cave and spectacularly blackening the sunset sky as the climax of his video Memory Bucket."

Sounds like Prozac to me!

(Note to Eli Lilly: Heh! Nothing personal!)

Reminder: the next Grand Rounds...

will be at The Examining Room of Dr. Charles. Deadline is Monday night at 8:00 pm.
I'm one of his many fans. For Grand Rounds #9, he sent three posts for consideration. Each one was a gem. I ended up linking to all of them. Is there a novel in his future?

Antidepressant use soars...

Is anyone surprised by this news, from the Washington Post?

One in 10 American women takes an antidepressant drug such as Prozac, Paxil or Zoloft, and the use of such drugs by all adults has nearly tripled in the last decade, according to the latest figures on American health released yesterday by the federal government...
In 2002, more than one in three doctor's office visits by women involved a prescription for an antidepressant, said Amy Bernstein, project director for the report issued by the Center for Mental Health Services of the Centers for Disease Control and Prevention...
"Factors affecting the recent increase in utilization of medications include the growth of third-party insurance coverage for drugs, the availability of successful new drugs, marketing to physicians and increasingly directly to consumers, and clinical guidelines recommending increased utilization of medications for conditions ...," the report concluded.
Julie Zito, a pharmaco-epidemiologist at the University of Maryland at Baltimore, said it is difficult to characterize as good or bad the increased use of drugs without studies that ask how people are faring as a result.

Antidepressants are not just prescribed for depression. Various antidepressants are used in the treatment of panic disorder, obsessive-compulsive disorder, eating disorders, social phobias, attention deficit disorder, neuropathic pain syndromes, sleep disorders, agitated dementia syndromes, and for smoking cessation. I've met patients who were unable to take hormone therapy for menopausal symptoms, because of side effects. They were given Prozac instead. Add in the patients with disabling depressive symptoms, and it's no surprise that the use of antidepressants is soaring. There also seems to be an increase in patients receiving two or more antidepressants simultaneously.

There are patients who literally can't survive or function without these meds. But how many truly receive the intended benefits? Are the benefits worth the risks for these thousands of people? Have non-pharmacologic treatments been considered, or tried? The lack of data is stunning. In the clinic, we examine medication use, one patient at a time. Every day, I ask: Is this treatment helping you? Is the medicine worthwhile? What might we do differently?

update: Thanks to Dr. Emer for including this in Grand Rounds 12...but do I think that the surge in antidepressants is not spectacular? I think it is spectacular...but I'm not surprised by it, based on what I see every day. We'll find out whether the FDA's new warnings will stem the tide.

Words of sense, about "PEST"

...or "Post Election Selection Trauma," as it's designated by a Florida psychologist. But why are they at the very end of the article?

The Boca Raton News reported last week that more than 45 South Florida Kerry supporters sought psychological help after the Democratic candidate conceded to Bush on Nov. 3.
That number, including 20 patients treated by Schooler, had risen to more than 50 by the weekend...
In addition to Schooler’s one-shot hypnotherapy, more than 30 people have called the non-profit American Health Association at 561-361-9091 to sign up for free support group therapy...
Executive Director Rob Gordon said Friday that AHA’s first election support group is scheduled for after Thanksgiving. The Boca-based charity, which has more than 500 professional and non-professional volunteers in Palm Beach and Broward counties, is offering the free sessions through the end of the year...
A psychologist at the Boca-based Center for Group Counseling, whose spokeswoman last Monday was referring depressed Kerry voters to the Democratic National Committee, said he thinks AHA and Schooler are unethically using the Kerry supporters’ misery for self-promotion.
“The word ‘trauma’ is overused and I haven’t seen Kerry voters traumatized according to the existing definition,” said William A. Weitz, adult program manager. “Certainly we’ve had people discussing their responses to the election at regular support group meetings, but the idea you would use hypnosis on them doesn’t make sense to me.”
Boca Mayor Steven L. Abrams, a Republican, said post-election therapy is “more of the same” in a city where people already spend tens of thousands of dollars a pop on plastic surgeons, beauticians and matchmakers.
“I do think it’s silly,” Abrams said.

Some comments from CJR about reporting on PEST:

When we first read the News' pieces about PEST, we thought perhaps we had stumbled across some Onion-style parody. The notion of Post Election Selection Trauma, a heretofore-undiagnosed affliction that came complete with its own absurd acronym and the backing of characters seemingly right out of a Carl Hiassen novel, strained credibility. Salai's pieces barely gave voice to dissenters within the psychological community, who might think the PEST diagnosis a bit overblown and grandiose...
The more interesting question was this: Why was the News earnestly publishing deadpan stories that the outside world couldn't resist ridiculing?

Even more interesting is the question: where are my psychiatric colleagues, and why haven't they weighed in on this? My own thoughts: this reeks of self-promotion (and self-parody). If people can't cope, then go ahead, offer help. We have plenty of acronyms for every kind of emotional misery and loss. We don't need a new acronym. We could probably do with a few less than we already have. But why aren't other psychiatrists commenting? Don't tell me they're all suffering from PEST!

(afterthought - I guess that with my blog entitled "shrinkette," I can't be too hard on people for self-parody....)

I knew it!

NYT: "What makes people happy? TV, Study Says"

Holiday tips

Upside down tree
Originally uploaded by shrinkette.

Our friend Robert hangs his fully-decorated Christmas tree upside down from the ceiling. It's quite a space-saver. (We weren't sure that his digital camera would work, as it has recently fallen into some mashed potatos and gravy. But I think this looks fine.)

Why we blog...

Bloggers explain, at Sandhill Trek.

Saint Nate has an excellent post...

about World AIDS Day:

Date of first officially recognized AIDS case in the USA: June 5, 1981

Number of people AIDS has killed worldwide since then: More than 20 million

Date of the first World AIDS Day: December 1, 1988

Number of known AIDS deaths in the United States that year: 4,855

Number in 2002:16,371

Total cumulative number of reported AIDS deaths in the USA by December 2002: 501,669

Please read the whole thing. (This looks like Grand Rounds material to me...)

Calling Protective Services...

Diane, at "The Write Wing," says she's a "nurse from a blue state." Here is one of her posts:

Me: You say you first noticed your child lost all vision 4 months ago?

Mom: Yes, something like that. I've been meaning to get it checked out, but I have 3 other kids and she's been dealing with it really well and all.

Me: Any allergies?

Mom: Yes, I think so.

Me: Do you know what they are?

Mom: Oh, those drug names are so hard to remember. If you call our old family doctor in Oklahoma, I'm sure he has it all written down.

Me: Do you have that doctor's name and number, by any chance?

Mom: Hmm. It started with an 'M' -- Miller? Monroe? Something like that. Or maybe it was Williams. He had brown hair and blue eyes. Do you have any idea how long this might take?

Unbelievable. Tragically, many in health care will not be surprised by this...

Rare insight

Haiku from Mr. Sun:

it is very odd
my whole family is weird
yet i am perfect

Other recent discoveries: via Morning Retort, an excellent post about nursing, from Geena.

We deal with every single kind of person imaginable: those who are demanding, scared, out of control, manipulative, unappreciative, violent, combative, crying, screaming, uncompliant, chatty, mentally ill, angry, depressed, confused, disoriented, critically ill, on the mend, thankful, kind, sleepy, or dead - both expected and unexpected...

Here's a daily round-up of popular posts. It's from MSNBC, which thinks that what we're doing is important. They linked to one of our Grand Rounds, which really helped to get the word out.

And in Say A Prayer, a woman chronicles her husband's difficult recovery from a stroke.

Regrettable trends

1. Inserting the words "blogs" or "bloggers" into time-worn phrases.(As in, "Those whom the gods would destroy, they first make bloggers," etc.) I've done this myself ("brave new blog"). I resolve to resist the urge!

2. Mainstream journalists and bloggers dissing each other. (Where are the adults?)

3. Appending the suffix "-pundit" to anything and everything. (It's more common than "-ette"...isn't it?)

4. Blog paraphernalia. ("Blog tattoos," for one.)

5. Spam comments. (Spam anywhere!)

6. Blogger apologizing profusely for its fainting spells, almost daily. (I really shouldn't complain, since it's still free...)

7. Staying up into the wee hours, staring at the Sitemeter. (Look...Singapore!)


(update - I don't know why medlogs delivers a page of code when asked to access this post. It doesn't happen consistently, though. Anyway I'm re-naming this and re-posting it, to see if it makes a difference...)

"What's a blog?"

Doctor's Lounge at lunchtime. We gossip about cases, families, hobbies, money. "Say, what's the price of gold? When did you buy it, how much did you pay?" My main asset is a gold-colored piggybank atop my desk, so I am silent. The surgeons gleefully disparage my knife-wielding skills, as I try to slice my entree. Then someone asks, "How's your blog?"

I thought they would never ask. "Let me show you!" We crowd around a terminal and I log on. Half the room asks, "What's a blog?"

Oh, dear. I try to explain. "You know, weblogs." More puzzled looks. We surf some sites, and then I show them mine.

They guffaw at the title. "Yes, I know, it sounds like an inept laundromat, but other names were already taken." One asks, "Are you like Wonkette?"

"No, your mother can read this one."

Then I show them Grand Rounds #9. Now they are interested. "Who wrote these things? Where did you get all this stuff?" I show them Nick's site, and Medlogs, and the roster of Grand Rounds. One wants to know if there's an infectious disease blog. "You can start one, for free, right now," I say.

Then someone asks, "Where are your ads? Don't you make money off the ads?"

"No ads," I say. "I don't know if Google will let me control them. They might be for...well..."

"For organ enhancement," says one.

Well, you should have heard them laugh! They think that's the perfect ad for a psychiatrist's blog. Then, lunchtime over, they are gone. No ads, I decide, because it seems...inappropriate. Besides, I have my piggybank, so who needs more revenue?

(Update: thanks to DoctorMental for including this in Grand Rounds. I changed the date to keep it at the top of the blog.)