Night of a thousand beeps

7 pm. Beep! It's a nurse. "Are you on call?" Yes, I am. An inpatient is anxious, agitated. Okay, let's figure this out. 7:30 pm: beep, again. Another patient has a headache. Not a new problem. Fine, we'll try to treat it. Thank you. 7:45 pm: beep, a pharmacy inquiring about a prescription. Easy question. Thanks. No problem.

8 pm. Beep. A confusing situation in the ER. Unfortunately, the patient can offer no meaningful history. The patient is on many meds, but can't tell us what they are. Much head-scratching and discussion about what might be going on. 9 pm. Beep! An inpatient psych patient with diabetes, and some rather high blood sugars. Page the hospitalist. Nice discussion about coordinating care. I love to work with colleagues in other specialties! Thank you, thank you. Good speaking to you. Goodnight.

10 pm. Beep. A suicidal patient at another hospital, in another city. Oregon has only two or three available psych beds. Tonight, they are mine to share. Is this patient okay for transfer? Yes? Okay, transfer. Bye.

Midnite: Beep. Nurse with question. 12:30: Beep. Another question. No problem. Thanks. 1 am: Beep. Patient in ER. Needs an assessment. Fine. And an admission. Okay.

2 am, 2:30 am, 2:45 am. Beep. Beep. 3 am, 3:15 am, 3:30 am. Now the nurse sounds sympathetic. "You aren't getting much sleep tonite, are you?" I ask, aren't I sleeping now? Isn't this my dream? She laughs. She has three patients to discuss.

4 am, 4:10 am, 4:20 am. Now the nurses apologize with every call. "I'm so, so sorry to wake you up like this!" They are so nice. I would be very grumpy, if I had enough energy. But I'm fighting a brain fog. Now the ER is calling, again...beep!

Let's wake up, here. Sit up. Waggle head. Move around a little. Turn on some lights. Waggle head some more. Be on! Now, call ER.

Hello?

"Sorry to wake you up! We need you for a few patients here."

No problem...except, excuse me for a moment, my beeper is going off again...

It is now 8:30 am, and I am officially off call.

Good night!

Inside jobs

When did it become acceptable for adult children to pilfer from parents?
"NYT: It's the Kids. Lock Up the China!"

It was not the first time Ms. Wilkner had swiped something from her mother. She often appropriated socks, spices, oatmeal, once even a chest of drawers she found in her mother's bedroom that had yet to be assembled. "That was a pretty good steal," Ms. Wilkner said. "Oh, I took a bookshelf, too. Clocks. I took artwork, a bunch of Monet prints. But my parents have plenty of artwork."

A generation ago, adult children visiting their parents' homes might have left with a Tupperware container of lasagna. Today, many of them stealthily make off with toiletries, groceries, sometimes clothing and even furniture. It is an apparently widespread practice, born of a sense of entitlement among young adults - and usually amusedly tolerated by parents - that gives new meaning to the phrase "home shopping." Like most adults, the pilferers have set up their own households, but they seem not to have given up the expectation that their parents should provide for them in certain ways. They loot their parents' houses to cut costs, or because they would rather not pay for incidentals. Or because they want things with sentimental value...Having grown up with a feeling of friendship with their parents, Dr. McAdams said, many young adults may feel comfortable taking their things. And parents, wanting to maintain the camaraderie, look the other way. Some even keep their cupboards full so there is plenty to go around...

Toilet paper is typically the first quarry in a life of petty thievery from parents' homes, many filchers said. During a visit the grown-up child notices an abundance of Charmin in a parent's bathroom, is perhaps reminded of the inferior brand in his or her own apartment, and suddenly decides to tuck a few rolls under an arm and deposit them in a knapsack. Soon the thief is taking other provisions. Toothpaste. Windex. Band-Aids. Electronics and home furnishings are not far behind.

"Ketchup and toilet paper are those things that you just really don't want to pay for," said Nicole Atkins, 26, a musician who lives in Brooklyn, adding that her parents "are generous to let me take their peanut butter and paper towels."

Debbie Jaffe, a 31-year-old actress, takes her mother's camera film. "She always has excess of everything," Ms. Jaffe said. "I took a printer recently. She had an extra."

But wait...not everyone approves!

Some parents balk at the practice of home shopping. They may remember reaching their own independence earlier in life, and how their parents had gone through the Great Depression and were extremely frugal. Taking things from them was out of the question.

"I think there is some resentment older adults might have," Dr. McAdams said, adding that these parents may see their children as "lacking focus."

Sorry, these kids seem extremely focused. They're focused on the stuff they want.

But these are generally not the parents whose homes get looted. The filchers often say they would never take items their parents truly valued. Many parents say they are amused, or even flattered, by the pilfering. "It means they need us," said Dr. McAdams, a father of two. "It's nice to be needed."

The phrase "emerging adulthood" does imply that these sticky fingers will eventually become independent. Is there a specific age by which one should finally accept the responsibility of paying one's way? Psychologists and economists point to the early or mid-30's.

"By the early 30's the assistance that kids are receiving from their parents dissipates strongly," said Robert F. Schoeni, an associate professor of economics and public policy at the University of Michigan in Ann Arbor. "The kids are establishing their careers, they're getting better-paid jobs, getting married."

Ms. Atkins, who has decorated her Brooklyn apartment with shot glasses, candles, Mexican marionettes and boxing gloves from her parents' house in Neptune, N.J., says she will cease her home shopping once she gets married and has a family.

"If I had kids and a husband, and I was still taking stuff from my parents," she said, "that would be really lame."

Is anyone feeling a bit judgmental about this blithe, rationalizing piece of fluff? Are the parents tacitly condoning this behavior by looking the other way, while their adult children make off with the goods?

Another wave

It started two hours ago. People are hunting for pro-anorexia websites, and landing on my site. (I am not "pro-ana," but I've blogged about these sites.)

They're coming from many parts of the globe. Most have never seen my blog before. Here's the log of my recent visitors, and the search terms that sent them (via Statcounter):

28 Jul 11:01:50 search.netscape.com on-pro-ana-websites
28 Jul 10:55:59 www.google.com pro-anorexia website
28 Jul 10:48:32 www.google.com pro-ana
28 Jul 10:46:39 www.google.com pro ana anorexia websites
28 Jul 10:39:55 search.yahoo.com pro ana websites
28 Jul 10:38:02 www.google.com anorexia is ok
28 Jul 10:37:52 www.google.ca pro ana
28 Jul 10:34:46 www.google.com pro anorexia websites
28 Jul 10:29:11 www.google.com pro ana websites
28 Jul 09:58:47 www.google.ca pro-ana photos
28 Jul 09:48:21 www.google.com pro-ana
28 Jul 09:47:33 www.google.com pro ana websites
28 Jul 09:40:19 search.yahoo.com pro ana websites
28 Jul 09:33:03 www.google.com pro anorexia website
28 Jul 09:26:13 www.google.ca pro-ana
28 Jul 09:22:15 www.google.com pro-ana blogger
28 Jul 09:20:09 www.google.com pro ana websites
28 Jul 09:18:01 www.google.co.th haldol familymedicine
28 Jul 09:11:33 www.google.com pro-ana
28 Jul 09:10:21 www.google.com ana websites

This last happened in May, when research about these sites was released. Why so much interest this morning? Has there been some news, or another research report? If anyone knows, please leave a comment. Thanks.

Grand Rounds #44: What do medbloggers do?

Pharyngula calls himself an "an accomplished neurosurgeon…it's just that all of my patients have been fish and insect embryos, and none of them have ever survived the operation." He's hosting our latest Grand Rounds, and he's done a terrific job. Go there at once!

The interview

Chuck Rose's animation walks us through his drawing of a beach house. He starts with an outline, some contours, a few guiding marks on the page. Gradually he builds up the image, adding details, depth, and color.

My first interview with a patient seems remarkably like Chuck's animation. I start with a few details: name, marital status, chief complaint (like anxiety, or depression). I have a bit more than one hour to form an idea of this patient in my mind, with a tentative diagnosis.

The interview is constructed to try to get specific information, and help the patient feel comfortable sharing it. (Who's comfortable at their first visit to a psychiatrist?! We have some hurdles that Chuck lacks.) What has she been doing up to this point? Can she tell me about important people and events in her life? What sorts of things has she been going through, and what has it been like for her?

I'd like to have a mental image of this unique person, doing something. (Such as, "leaping before she looks," or "not thinking before she acts." Or any number of things that can cause problems.)

But since I'm constructing an image for myself...I have to be careful. How good is my idea of the patient? Is it leading me in the right direction? I ask, and ask again. The image is bound to change as I learn more about the patient, and as the patient learns more about herself.

If we don't question and refine it, my formulation won't help me or the patient. We'll just have something suitable for framing...like Chuck's beautiful beach house.

Where's my Flapdoodle?

It's powerful. It's magical. It gives us whatever we ask it for...as long as it's good. Never bad, only good. The ultimate gadget for wish-fulfillment: the "Flapdoodle."

Psychiatrists explore patients' wishes. What do they want from themselves, from others, from life? How have they tried to reach their goals? What's working, and what isn't? Sometimes we'll ask: If you could have three wishes, whatever you want, what would you ask for?

Some hesitate. They're afraid to ask for anything. Others have a list. Some start with general things, like "world peace, no more hunger, no more illness." Then we might say: Okay, you have three more wishes. Anything you want.

More wishes? Anything? Now, heartfelt wishes might emerge: I want people to respect me. I want to be a better parent. I want to erase my past. I want meds and psychiatrists out of my life, forever. I want to feel like a person.

Ah, now we're talking! Now we can start to look at the connection between desires and behavior. We can assess goals. We can talk about healthy ways to reach goals.

But, unfortunately...I'm not "Dr. Flapdoodle." Although I would love to own one of those gadgets. That "Electromindomizer" looks pretty good, too.

Again?

More "major incidents." There's one casualty. What can it be like in London now?

Here's the paramedic at Random Acts, shrugging and pouring tea. Here are many links from Instapundit, and here's what Sullivan is watching. Here's one Tube passenger, in Times of London:

Another man, who declined to give his name, said: “It’s become part of life, I’m very calm about it. They want to terrorise us, so we must not let them.”

And what's this? One of the July 7 bombers might have an Oregon connection.

Must focus on patients. Must not surf these sites, yet. But we know what some patients will be talking about today...

"My Dog Is Tom Cruise"

In the New Yorker:

"I have to tell you, things are good. I am . . . I am . . . Whooo! . . . I am very good. I just returned from a walk and . . . ha! Things. Are. Good. I’ve got a bowl of hard kibble with some soft stuff mixed in. My name’s on the bowl! I am passionate about this lamb-and-rice recipe. What’s been going on? haha!
...Do you know the history of crate training? ’Cause I do. Don’t talk about things you don’t understand. Like saying dogs are wild. Dogs are wild—that is glib. Dogs are . . . I’ve done the research; there are crates that they put us in to quote unquote train us. They throw rattlesnakes at us. Electric-shock tags! I’m not making this up. This is . . . it’s history. Crate training just masks the problem. These dogs, they become zombies. You can totally handle disobedience naturally by saying 'No!' and 'Bad dog!' It works. Look at the facts. Shock tags?! I am disgusted."

(by NOAH BAUMBACH)

"Why I became a physician"

And not just any type of physician. Here's Red State Moron:

I was four or five when my brother died in-utero. I remember that my mom was pregnant. I remember she went to the hospital, and then came home, but without a baby. And I remember that she and my dad were really, really sad. Traumatized. And they couldn't have any more children.

I told these stories to my friend the psychotherapist the other night; my daughter's only child lament, my parent's trauma. His eyes lit up in some sort of psycho-therapeutic orgasm, and I knew, immediately, what was coming next. Why I chose medicine; why I chose obstetrics, especially high risk obstetrics. Almost seems too obvious, doesn't it? Only child pursues career in which he deals daily with the trauma of high risk pregnancies, and the trauma experienced by the patients and their families.
Now, why the hell would I do that?

We can't discuss our patients easily in these blogs (unless we're constantly saying, "My colleague from another city told me about this case," before proceeding.) But we are certainly talking about ourselves. This is self-disclosure that many would hide from psychiatrists. (Many would hide it from their blogs!) And whatever we think of Freud, his ideas can still resonate.

Doctors are sometimes thought to have "repetition compulsion," when they've had a childhood trauma that involves illness. The anxiety of that trauma didn't simply go away. The theory goes that, as doctors, they're still - unconsciously - trying to fix that original trauma, and relieve that anxiety. Does it work? Not always. Google yielded some articles on this, and a joke:

Final Exam, Item 12.
Define Sigmund Freud's theory of repetition compulsion.
Wrong. Try again.

My colleague from another city told me about a blogging psychiatrist whose parents had a very, very sick baby when she was young. Mom was frantic, dad was screaming, and everyone was terrified, including the future blogging psychiatrist. It was the most frightening thing she had ever seen. Ultimately she went to med school, and actually did a few years of internal medicine...learning about medical emergencies and treatment. And then she switched to psychiatry, and learned about treating anxiety, and coping with trauma.

Sounds like repetition compulsion?

Staying cool

A summer heat wave has settled over Eugene. It's not often over 90 degrees here. Yesterday it reached 98. My office, however, is freezing, and the air conditioner won't listen to reason. Specialists have been consulted, and we tiptoe around them as they work. We aren't complaining...too much.

We worry about our patients during heat waves. Some psych meds can make patients particularly vulnerable to heat-related illnesses.

For anyone out there who is sweltering: here's some advice. And for inspiration, if not relief, here are some shots of the Harbin Snow and Ice Festival:

How does Lance Armstrong do it?

There's a name for this behavior:

'He pays attention to every last detail that contributes to the pursuit of excellence. That's what sets him apart,' believes Dave Brailsford, the performance director at British Cycling. 'He is always looking to make a tiny improvement to his nutrition, his position on the bike, or the science of how he trains.'

Thus he avoids ice cream, in case it causes indigestion, or carbonated water, lest it induce diarrhoea, or chocolate mousse - excessive sweating - and does not shave his legs the night before racing, in case the minimal energy required to regrow the hair makes a difference. (Emphasis added.)

Who knew that a champion cyclist risks defeat if he shaves his legs before a race? The author skims past this observation. He dwells more on Mr. Armstrong's experience with testicular cancer:

...Armstrong is a survivor. 'Although the Tour is excruciatingly painful, for Lance it is still not as tough a battle as when he overcame testicular cancer,' explains Doyle. 'That means that he is mentally strong, very driven and has a lot higher pain threshold than the other guys because he's beaten a life-threatening disease. He can suffer that bit more.'

Cancer gave Armstrong the worst times of his life. Hearing he had a 60 per chance of dying. Having surgery to remove one testis. Chemotherapy to fight tumours that had spread to his lungs and brain. Five months in hospital as he defied doctors' expectations. But illness was also the making of him.

'In a strange way cancer did him a huge favour,' says Daniel Coyle, author of the recent biography Lance Armstrong: Tour de Force . 'It removed 15lbs of muscle and resculpted his body into the leaner shape. Before then he had been too big and too muscular, especially in the upper body. And it gave him the discipline that, allied to his talent, turned him into the sporting phenomenon he is today...

Grand Rounds #43

Aggravated DocSurg hosts the latest edition of our favorite medical blogging. He's linked to some wonderful posts. Be sure to check it out!

Portraits of a family crisis

Laureline is an artist. Her 81-year-old mother has fallen and broken her hip. Laureline wants a turn at the "celestial rewind button." As she ponders an uncertain future, she sketches her mother, her father, and hospital scenes:








(See Laureline's blog for larger views.)

Laureline's mom was caring for her demented husband. Who will shoulder that responsibility now? The dilemma is a common one (and growing more common, unfortunately). A few books might be helpful: The 36 Hour Day, and The Mayo Clinic On Alzheimer's Disease. Local chapters of the Alzheimer's Association can also give advice. But solutions are seldom easy.

Parting words

...blurted out by a new patient, at the end of a white-knuckled interview:

"You aren't the ogre I thought you would be!"

Er, thanks.

Grand Rounds #42

Welcome to Grand Rounds, a weekly roundup of our best medical blogging. Aggravated DocSurg hosts next week.

Top story: A London EMT blogs about terrorist bombings, at Random Acts of Reality.

"...Once the shock had settled, I started to feel immense pride that the LAS, the other emergency services, the hospitals, and all the other support groups and organisations were all doing such an excellent job. To my eyes it seemed that the Major Incident planning was going smoothly, turning chaos into order."

Newsweek then reports on his blogging, in “History’s New First Draft.” Our thoughts and prayers are with the victims and their families. More at Medpundit, Intueri, and Infoisfree.

Other medblogging highlights:

July on the wards. New interns, new residents. How's it going? Dr. Chaplin finds that it’s the toughest job he’ll ever love:

Student: "Did you make it home okay post-call?"
Me: "Sure! I only fell asleep once I pulled into the driveway."

Dr. Michele Au begins her Anesthesia residency, and finds that it's like flying an airplane.

It's the takeoffs and landings that are the really scary parts (corresponding of course to inducing the patient and waking them up at the end), but the difference is that at this point, the time in flight is scary for me too...

What happens when a resident asks for help? At Intueri, Maria finds out:

The flush burned my face. I shouldn’t have asked for help. I should just suck it up and write all the notes. But am I SUPPOSED to carry the whole service? Am I supposed to write notes on everyone? What is the fellow supposed to do? How did this happen? Why do I feel bad for asking for help?

(Note: it's not always like that! -Ed.)

How to pay for these residents? Medrants worries about drug company funding of residency positions. He notes the dilemmas:

Currently, we rely heavily on federal funding through Medicare. This reliance does “handcuff” medicine in its own way. We have fixed numbers of “slots”, which do not necessarily match changing needs and opportunities...

Blogging about your patients? Clinical Cases and Images Blog discusses federal privacy rules, so we can all sleep better at night. (Note to housestaff: yes, you will sleep again.) Some patients are disappointed that they’re not in her blog, notes Jassy Timberlake.

Dr. Charles reflects on a teen’s labor and delivery.

Sodden black curls burst forth, a new face with light freckles,
next chin, then neck, then shoulders. Teenage mother
gave a final big push...

In "Storm Warning," the Cheerful Oncologist's allegory, medical disaster looms like an approaching hurricane. Get ready for a shock! And are we prepared for large-scale disasters? MSSPNexus Blog writes about Disaster Preparedness in Healthcare.

“Video robots” help a urologist make rounds at Johns Hopkins. Medviews is incredulous:

A lumbering robot, C3PO like, wheels itself into a patient room, and the video doc asks how the patient is doing….
A robotic meeting diminishes the sense of a patient’s worth to the physician. He or she is just not important enough to get the big kahunah’s personal time.

Some docs would leave video robots in the dust. The Cheerful Oncologist instructs us in the art of "Lightning Rounds:"

You’ve all come across doctors who blow through their weekend rounds like a Cigarette boat on the lake at sunrise. This unfortunate focus on brevity tends to leave behind patients and families who have no idea what is going on, not to mention progress notes that bear an uncanny resemblance to line twenty-six of the Rosetta Stone...

The envelope, please. Creative Blogging Award goes to Orac, for his inspired attack on certain fallacies about autism: "The Hitler Zombie Smells Thimerosol."

Deep within a dark crypt, far beneath the ground, it slept. The air was thick and musty, and the crypt utterly silent, so silent that its heartbeat would easily have been heard, if it actually had a beating heart...

Ask the medbloggers. How do I survive a deposition? Dr. Tony has tips. Is there a feed for audio files offered by NEJM? There is now; Kidneynotes has created one. What is an HSA? Insureblog tells us, in Parts 1, 2, and 3.
Why can’t I get insurance? HealthyConcerns wants to hear from you.

Why know baby’s gender sooner? This doula has thoughts. What is a Health Buddy? Tim Gee has the scoop. (Think "video-robot-doctor-lite." The photo shows a handheld device that asks, “How do you feel today?” One more step toward the demise of my career…) And how was your first Trauma Call? This med student tells all.

Diabetes Mine. Amy Tenderich's blog offers more than tips for controlling blood sugar. She gives us insights into the lives of diabetics. Here, she posts on the trail of debris that follows her, when she tests her glucose.

Medical Waste: Red State Moron recalls a time when precautions were few. Wasted Meds: Where do discarded meds go? Look to the Great Outdoors. Interested Participant wonders what should be done about it.

Making the diagnosis: Kevin, MD comments on cognitive errors that can lead to missed diagnoses. See the comment thread for a debate about which tests are "reasonable and necessary." And Jeff Jennings points to a blog that's devoted exclusively to difficult diagnoses: Pulmonary Roundtable, for baffling pulmonary and critical care cases.

"It's not evil, it's research."...Or, so they might have thought. Dr. Maurice Bernstein, of Bioethics Discussion Blog, points to a chronology of experiments on humans, starting with the 6th century BC. Yes, it omits many good, ethical experiments. But Dr. Maurice urges us to read it anyway.

I think that human research whether medical, psychiatric or social science or others involving human subjects is not some activity where the ethics should ever be forgotten. Just as we remember those scientists who made the wonderful medical discoveries which has saved lives and discomfort, we should also keep a list of bad and sad experiments and understand why the system of reseach should be fixed so that the ethical failings of these and others of similar ilk are never again repeated. ...Maurice.

Alcohol and street drugs. Dr. Emer, at Parallel Universes, discusses the surge in meth production in the Philippines. GruntDoc helps police take a drunken driver off the road:

"I am sitting next to a car stopped in oncoming traffic at (location). The driver looks like he's either asleep or dead". (I was pretty sure he was alive, but not taking chances)...

Generics go global. It's tough all the way down the pharma food chain, says David Williams at Health Business Blog. Price competition for generic drugs is intense, as Indian companies enter the market. Can China be far behind? Still, consumers' prices haven't dropped.

Scamming scammers. The Krafty Librarian, on fake medical research:

My question for the blog readers...
What happens to the bad research?

Is this the darkest Grand Rounds ever? (And why wouldn't it be, this week?) Here, try this post: "Only Love Makes Sense," from About a Nurse. A simple, sensitive post about how love heals. In fact, just talking about love is healing for May's aphasic patient. Illness, pain, loss, memory, longing, intimacy, and caring...it's all here. (No video-robot-nursing for May!)

And here's some good news: Corpus Callosum sends word that SARS research may benefit those who suffer from other causes of respiratory failure. Dr. Andy is cautiously optimistic about a potential treatment for ulcerative colitis.

I see deep caring and commitment in all of these posts. Thanks to all who submitted their work. Prior Grand Rounds here, and submission criteria here. Contact Nick at Blogborygmi, and tell him that you want to host Grand Rounds.

Curb those blogging excesses

At Notes from the Hinterlands:

Do you find yourself surfing from blog to blog, pausing only long enough to read the title before moving on? Have you modified your template more than 50 times? Do you check the site counter on your blog more than 10 times per day to see how many visitors you have had? Do you spend hours each day using Blog Explosion in order to increase traffic to your blog? Have you added so many features to your sidebar that it is longer than your posts? Does your blog have more than 500 links to other blogs? Do you post mindless drivel just so that you can say that you have updated your blog?

If you answered 'yes' to any of these questions, BlogObsession: The Cure might be just the book for you...

...While the desire for visitors to one's blog is normal, the potential for obsession with this aspect of blogging is particularly strong. Chapter 4 describes the minimal traffic complex and suggests both coping strategies and, for those in greatest peril of effects bordering on pathology, suggestions for prescription medications. This chapter will be particularly useful for medical professionals whose patients present with blogobsession...

Panic

What does a panic attack feel like?

"...please allow me to introduce you to anxiety’s lecherous uncle, panic. Please allow me to tell you through these tears about my new EXECUTIONER. Let me tell you about the most intense feeling you will ever feel beyond love, beyond orgasm, beyond childbirth, beyond intoxication, beyond heroin, beyond the feeling in your throat as your plane is going down...

"…creeping up when you are doing something benign; folding laundry, washing the dishes, reading a book, talking to your partner, laughing about something funny that happened at work, and unlike anxiety where you get a tap on the shoulder that says, “Uh, excuse me…it’s time for your anxiety attack,” PANIC forms itself before you without your knowledge and is shot with the piercing speed of an M72-66mm LAWSs rocket right through your fucking chest.

"It is gonna blow a hole through you with enough speed to knock you back fifty feet..."

-from Tracy, at Time For Your Meds. More on panic disorder here.

Social psychology of the bow tie

A Red Flag That Comes in Many Colors - New York Times: "To its devotees the bow tie suggests iconoclasm of an Old World sort, a fusty adherence to a contrarian point of view. The bow tie hints at intellectualism, real or feigned, and sometimes suggests technical acumen, perhaps because it is so hard to tie. Bow ties are worn by magicians, country doctors, lawyers and professors and by people hoping to look like the above. But perhaps most of all, wearing a bow tie is a way of broadcasting an aggressive lack of concern for what other people think.

'It's almost designed to provoke hostility,' Mr. Carlson said."

Call for Grand Rounds submissions

Wanted: timely, engaging, health-related posts for the next Grand Rounds. I've received some wonderful posts, but would love to have some more. My e-mail address is shrinkette01 followed by @earthlink.net. Deadline is Monday, July 11, at 9:00 pm Pacific time.

We are all Britons now

I've paced those streets. From Regents Park to Kensington, and from Russell Square to St. James...I've memorized those walks. Just me and London, together. We've been friends for years.

How terrible that no one can be surprised by bombings anymore.

I think of what I've said, reflecting on 9/11:

"In memory, it is akin to a natural disaster. I have to remind myself that it was an act by people." And, "...we have enemies, a fact that I too easily edit out of my consciousness."

A Today Show exclusive

The past few weeks have been full of excitement for Serotonin, a neurotransmitter that modulates mood and behavior. "Today" host Matt Lauer sat down with the molecule, and talked about his recent work, as well as Tom Cruise's comments.

Matt Lauer: Anything at all interesting happening in your life these days?

Serotonin: Matt, I was on Capitol Hill last week, testifying about Prozac and suicide. And I'm helping NIMH with a novel antidepressant that will only make people feel good when they do good...when they, you know, do good things for others. We think it's the next big thing.

Lauer: Did you see the Cruise interview?

Serotonin: I did, Matt. We watched it at APA headquarters. I can tell you, the mood was grim.

Lauer: How did they react?

Serotonin: Matt, Psychiatry has always had enemies. But Cruise's outfit is unique. They have religious zeal, and they have resources. And they use them. A forceful, determined man like Cruise, with his mind made up...well, you probably felt it yourself.

Lauer: Like a steamroller.

Serotonin: An influential steamroller...at least, potentially so.

Lauer: What do you make of his arguments?

Serotonin: It's not hard to argue against psychiatry, but his particular arguments showed some pretty significant distortions...

Lauer: Give us an example.

Serotonin: Well, he said, "There's no such thing as a chemical imbalance." Matt, I'm a brain chemical myself. I can answer this.

Lauer: Please!

Serotonin: When psychiatrists talk about "chemical imbalances in the brain," they're talking about a theory. They're referring to our best guess about how drugs like Prozac work. The way they think about it is, first, there's a set of serious symptoms, that we call depression. There are drugs that reliably improve these symptoms, to a greater extent than placebos, in controlled studies.

Lauer: Sometimes, not much more than placebo, right?

Serotonin: Right. But, nonetheless. The drug improves the symptoms, and shortens the time to recovery. Then we look at this drug in the lab and ask, how does it work? What does this drug do? In the lab, the drug affects the activity of brain chemicals...including, yours truly.

Lauer: You see this in the lab.

Serotonin: Right. So, how do you explain all this? There's a theory: in depression, the brain chemicals are not balanced, and these drugs help to restore the balance. So in a way, there's a grain of truth to what he's saying: no one has ever shown definitely, "here is exactly what a 'normal' balance really is, and here is the precise 'chemical imbalance' that causes depression." We're still working on it.

But is psychiatry a sham, because we don't have all this worked out yet? Depression can be life-threatening, and we have meds that help most people. Do we not use these meds, because we can't define the chemical balance? What is the wise use of these meds? That's the real question.

Lauer: Can you measure my chemical balance with a blood test?

Serotonin: There's no blood test. To diagnose depression today, you need history, you look for signs and symptoms...I don't know if we'll ever have a blood test. Really, Matt, there are so many things to measure...it's so complicated. There are hormones, there are genetic factors...

Lauer: Right. We've invited DNA to speak here tomorrow on the Today Show, and we'll ask him some more about that. But tell me, what about psychological factors and depression?

Serotonin: Ah! This is a favorite subject of mine. Which patients get the most improvement in their depression? The ones who get both psychotherapy and meds. They do better than those who get meds alone. Now, why is that?

Lauer: Why is that?

Serotonin: We don't know why, but it's true. We think depression has biological, psychological, and social roots. The best treatments address all those factors. Are we discovering that an idea can change emotions, and change behavior? That something that occurs during psychotherapy can change the so-called "chemical balance in the brain?" Again, it's a theory. Many scientists are hot on the trail of this one.

Lauer: It's an exciting time. Thank you, Serotonin, and best of luck on your projects!

Serotonin: Thanks, Matt.