How Not to Die a Tragic Death from a Drug Overdose

Whitney Houston, Michael Jackson, Heath Ledger, Amy Winehouse, Anna Nicole Smith -- I imagine you know what these celebrities all have in common: they've died from accidental overdoses.

In the first 20 years of my career, I can't recall hearing a single story of an accidental overdose resulting in the death of a young person that I knew, a friend knew, or a patient told me about.  Maybe I've forgotten them, but if so, it's because they were spaced well apart and there weren't memorable trends. One close friend had a young relative, a substance abuser, overdose and end up in an ICU, but he lived.  Somehow, in the past year, I've been hearing more and more stories of tragic deaths of young people, full of life and promise, who partied just a little too hard and stopped their lives in it's tracks.  Not suicides, just a little too much of whatever the substances might be.  

So young people party.  They drink, they smoke weed, and sometimes they pop pills or shoot drugs (though please do note that IV drug use is not considered to be "recreational.")  Given that this is the reality of some people's youths, and these stories are heart breaking, let me offer some words of wisdom.  It's not just the hardcore addicts who are dying, it's not just the shooters, and often the deaths are caused by medications with legal uses.   And the horror of the deaths is not just their tragedy, but the guilt that gets left behind, by the person who left the victim alone, who noticed they seemed off but not enough to call an ambulance, by the person who didn't think much of an unanswered call or text and gets to wonder if they had done something differently, if their friend might have lived.  It's all horrible.

Here are my words of wisdom:

Only take one substance.

Don't drink and take drugs.  Don't do it even if you've done it 2,413 times and it was fine all those times,  Many people who die accidentally have lots of experience with it and have never died before.

Don't mix drugs.  Benzodiazepines may be relatively safe, but once you take your Xanax, add a little oxycontin, and have a beer, you may be in for a very long sleep.  Xanax/Valium/Ativan/Klonopin (benzos) and Oxycontin/Oxycodone/heroin/methadone/morphine/MS contin/percocet/percodan/darvocet/demoral (opiates)  --- these medications have effects that are more than additive and they cause respiratory depression and have unpredictable effects.  This combination of xanax/alcohol/pain killers seems to be especially popular and especially lethal.  Cocaine and stimulants are also a really bad idea.

If you've had a drug problem, quit using, and have been clean for more then a few days, your body starts to heal, and if you relapse, it will take much less drug to get the same effect,  Taking your old dose of medication can be lethal.  This is a major reason why death rates are so high soon after prisoners are released from jail -- they hit the streets and take their former dose of drugs -- it's much more than their body can handle after being clean.

Don't drink on an empty stomach.  Food slows absorption.  The body is made to resist dying from alcohol poisoning -- it's why people throw up, it keeps them from absorbing too much alcohol.  You can overwhelm this safety mechanism if you drink too fast.  

---Don't do shots.  See the above logic.  It's hard to kill yourself drinking beer alone, but I've heard of people doing 21 shots on their 21st birthday or drinking an entire bottle of straight vodka as part of a frat initiation.  This can kill you.  If you must do shots, don't do them on an empty stomach, let a fair amount of time pass between shots, and drink a non-alcoholic drink in between to slow the process down. 

----If you must drink heavily, do it with friends and stay with each other, don't lose your drunk friends.  Don't leave someone who has passed out alone, roll them on their side so that if they vomit they don't aspirate it (aspirate = breathing your puke into your lungs, a common reason people die after heavy drinking or overdosing).  If someone can not be aroused after drinking, call an ambulance! It's better to be embarrassed than to be dead.  Remember, you don't have to be an alcoholic to die of alcohol poisoning.

-----Don't drink and drive.  There is a cab driver out there who needs your business. 
-----Don't drink and go on the roof.
-----Don't drink and walk on railroad tracks.

If you take prescription drugs for medical reasons, don't increase the dose without checking with your doctor first.  If you're not sure if it's safe to combine prescription drugs, ask your doctor or call a pharmacist (any pharmacist, look for a 24 hour pharmacy and call and ask to talk with the pharmacist.)

And probably the best advice: don't abuse drugs or alcohol.  

If you take prescription pain killers, sedatives, or stimulants,  know where they are, and know that someone else can't access them.  These medications aren't meant to be shared.

New CPT Codes Are a Coming

 

In 2013, the CPT codes that healthys use will be changing.  The new ones are said to better reflect what we do.  What does that mean?  Hmmm, I don't know, I thought I'd ask you.  The code for pharmacologic management, the so-called "med check" with no time requirements, is going away, and psychotherapy codes will be for 30, 45, and 60 minutes.  I'm not sure what happens to the 50 minute hour.  I'm going to try to figure this stuff out over the next month and write about it here or on Clinical Psychiatry News.  But first, let me ask you a few questions (these are for mental health professionals only, but everyone else,  hang on, I'll have other questions.  

Do you use CPT codes now?
Are you worried about the changes that are coming?
Do you think this will increase reimbursement to you?
Do you think it will increase reimbursement to your patients?
How do you plan to learn the new codes?
Oh, I'm going to set up a poll, but do feel free to write in on the comment section!

You voted for WHO??

Please don't forget to vote, no matter who you support.

The Trauma Recovery Movement: Where Did It Come From?

For anybody who's interested, you can follow along with me as I learn about this stuff. I put the tape measure pic up because I'm learning about trauma treatment and outcome measures.

I was curious about SAMSHA's National Center for Trauma-Informed Care so I did a little background reading based on material I found on their web site. (And if there's anybody reading involved in this who would like to jump in and provide more information, please do. Shrink Rap also allows guest posts!)

It appears that this arose out of a SAMSHA initiative to encourage study of innovative program delivery systems. It was recognized that certain groups of people had severe and overlapping treatment issues. In other words, there were women with high levels of childhood abuse, adult violence, mental health issues and substance abuse. They wanted to figure out how to best provide treatment to these folks and they theorized that the key link or ingredient, a "cause" if you will, was the trauma history.

A two-phase, multisite study was designed to look at this problem. (1) In the second phase, nine cities were selected to participate. They enrolled thousands of women in a variety of treatment settings. The women all had one or more of the three issues: trauma history, substance abuse and mental health problems. One key fault is that there was a non-random assignment of the patients: they were allowed to self-select the "intervention" versus "usual care" condition. Both the trauma and usual care groups provided mental health and substance abuse counselling. The trauma group was additionally provided a women-only therapy group that employed one of four trauma treatment recovery models. The usual care group provided some additional not clearly specified intervention (I didn't have time to read in detail, it sounded like a generic social skills group).

The results were difficult to interpret because it turned out that two of the nine sites had significantly different study subjects. They had to break out certain sites from the rest to analyze the data. However, when pooled two interesting findings came out: the first was that a program that integrated all services (mental health, substance abuse and trauma/generic) was better than a program that offered disjunctive services. The second finding was that the more core services the patient used, there was a slight but significantly worse outcome. (2)

Outcomes were measured at six and twelve months. Overall mental health scores were measured using the Global Severity Index (GSI) and the Brief Symptom Inventory (BSI). Mental health status was improved more when services where combined, even when there was no change in addiction severity. Traumatic symptoms also improved.

What I take away from this is: integrated treatment is better.

That doesn't surprise me. Maryland is reorganizing it's public health services to reflect this, and the Affordable Care Act also recognizes this. There's also been at least one study (I've got it pinned on my pInterest board) which showed that integrated care post-release can decrease felony recidivism.

But improvement with integrated care does not prove that the treatment effect comes from treating the trauma. I think that's the mistake. This model can be useful for anyone with complicated co-occurring conditions, male or female, traumatized or not.

OK, I'll shut up now. What's new with you, Dinah?



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1. McHugo, et al. Women, Co-occurring disorders, and Violence Study: Evaluation design and study population. Journal of Substance Abuse Treatment 28: 91-107, 2005

2. Morrissey et. al. Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services 56: 1213-1222, 2005

Yes, You're Better

One of the fun things about Shrink Rap is that periodically ClinkShrink and I like to wrap our hands around each others' necks and squeeze really hard while screaming.  

So let me refer you to ClinkShrink's post below,  Am I Recovered Yet.  Read that first and come back.  It's a rich post with many different agendas. Don't worry,  we are on opposites sides of town and we are both getting sufficient airflow. 

1.  Clink talks about Tonier Cain who was horribly abused as a child, both physically and sexually.  Ms. Cain's abuse led her to a dysfunctional life of drug abuse, prostitution, and repeated incarcerations.  By dealing (whatever that means) with her trauma, she has overcome these problems, she now lectures on the importance of dealing with trauma, and she is a productive member of society.  I know nothing about Ms. Cain, this is what I gleaned from ClinkShrink's post.

2. Because of Ms. Cain's efforts, laws have been passed requiring that anyone working in a state facility must be trained in trauma-informed care, which ClinkShrink tells us has not been proven to be effective in studies. Remember, Ms. Cain is an individual who benefited, and studies look at populations, not individuals.

----Dinah's commentary:  I am going to stay out of the evidence-based medicine question because, well, evidence-based studies are limiting, they don't look at the full range of what we do clinically, studies are often conflicting, and sadly, we've seen that pharmaceutical companies have skewed some studies.  
      Moving on, I am against the concept of legislating medical care and medical standards.  I agree with Clink (take a breath now) that there should not be laws requiring training in trauma-informed care.  There should be industry standards and mandates; lawmakers shouldn't be requiring CPR training.  The law doesn't require me to have a flu shot.  My hospital, however, has said that if I'd like to continue treating patients there, I need a flu shot (I had a flu shot).  There was a really nice article on the intrusion of legislation into the practice of medicine a few weeks ago in The New England Journal of Medicine, see  "Legislative Interference With the Physician-Patient Relationship."

3.  Clink goes on to question whether Ms. Cain is really better if she continues to be fixated on issues related to her trauma.  Wow.  Let's see, she was a  homeless, drug abusing, criminal who sucked resources from society (I'm assuming that the tax payer funded her forays into prison) who now living in free society, working to help others, on a mission (I love people who have missions), and doing well for herself.  Yup, she's better.  Is she cured?  I don't know.  I don't even care. I'm with the commenter who suggested that the patient is the one who determines better.  She's feeling good about herself, presumably making a living (there's an award winning movie), lobbying for something she believes in, looks like she's raising her kids, getting a message across.  She's not homeless, not smoking crack, not in jail.  Does she need to be an accountant to be 'better?"  Plenty of people get better by focusing on their past problems.  Is the incarcerated drug addict who later becomes an employed addictions counselor who helps others not 'better' because he still lives his days thinking about addiction-related issues?  Yes, they are better.  Is it any different from the person who goes on to be an oncologist because his mother died or cancer, or the person who becomes a healthy because he had personal or family experience with psychiatric problems?  What about my short friend who became a pediatric endocrinologist?

4.  Is she Cured?  Clink defines this as being symptom-free, able to move on to a life not involving a focus on their problems,who no longer requires resources and frees up these scarce resources so that others can use them.  What a funny way to define "cure" in a field where 'serious mental illnesses' are often chronic or recurrent.  I'll go with Freud here: "Well" is about the ability to work and to love.  It's not about the ability to live life free of symptoms. Is she Cured?  What does is matter?  Why does that need to be judged?

5.  Clink tells us that her goal is to get someone to zero symptoms (--I would never qualify, I didn't sleep well last night as I was worried about the election) and free them of being her patient.  "Government money for mental health services is limited, and should be directed toward people with serious mental illnesses and evidence based practices."

I'm not sure what ClinkShrink is getting at here.  I agree that government money should not be used for mandating training in trauma-informed care.  We don't mandate training in schizophrenia (it comes as part of psychiatry residency training and it's mandated by those who oversee residency training programs, not legislators).  I'm not sure what she means by 'government money' or by 'serious mental illnesses.'  So a patient with Medicare should not be allowed to access mental health services for a mild mental illness?  What's mild? Anxiety?  Election-angst?  Irritability with co-workers?  What if a person finds that a medication or a regular psychotherapy appointment helps their personal comfort level, and that by maximizing their comfort, they are better able to function as a parent and thus help a future generation?  What if having somewhere to process their issues makes it easier for them to function as a surgeon, or as a teacher. Okay, you say, not government funds.  But then what if our surgeon who feels better with care, or our legislator who influences the lives of thousands, or our public health researcher who benefits from care, what if they turn 65 and are now having services paid for by Medicare, do we bounce them off?   We don't tell people they can't have repeated doctor's appointments for belly pain, why should we limit care to those with "serious mental illness" whatever that is.  

Okay, I'm ranting. Clink, let go of my neck now. 

Am I Recovered Yet?

Today on our local public radio station I heard an interview with Tonier Cain, a team leader for the National Center for Trauma Informed Care. Ms. Cain is a renown speaker who has appeared at multiple national venues to talk about her horrific childhood history of sexual and physical abuse, multiple adult arrests, history of prostitution and drug abuse, and incarceration in our own Maryland prison system. Her story is remarkable for her 180 degree transformation to become an accomplished organizer and advocate. She has repeated her narrative many times online, on the radio, and even in local theater. She frequently speaks to women prisoners to talk about the importance of trauma recovery therapy.

I was familiar with her story because the state of Maryland passed a law last year which mandated that anyone working in a state facility must be given training in trauma-informed care. I went through this training myself where I saw a shortened version of the documentary "Healing Neen," about Ms. Cain. Following the presentation the instructor asked what we thought about the film. Everyone in the room thought that it was wonderful, that Ms. Cain's story was amazing, that the trauma recovery treatment she had had was miraculous.

"Isn't it amazing how she has overcome her trauma?" the instructor asked.

I should have kept my mouth shut. I really should have.

But I couldn't help myself.

"But she hasn't recovered!" I blurted out. "She just reshaped it. She has recreated her personal and professional identity around her trauma narrative." And that's true---she is now a professional trauma victim/survivor. How is this overcoming her past? How is this recovery?

The room fell silent. People looked at me, a bit aghast and shocked. Some people tried to explain: "Well, you don't ever really COMPLETELY overcome the past, you just learn to live with it."

Well OK, that sounded reasonable. But wasn't the point of the trauma recovery movement that you actually are supposed to recover? That at some point, you stop being a patient? I mean, when I treat someone my goal is complete recovery----zero symptoms----that's what I call recovery. My goal is to free someone from being my patient, as much as possible.  Isn't that the goal of the trauma-recovery movement?

Maybe I just was uninformed. Maybe I needed to read more about it.

I did a PubMed search using the terms "outcome" and "trauma-informed care." This search produced all of four articles. One focussed solely on trauma-informed interventions to reduce seclusion and restraints in the hospital. Another paper discussed the dirth of outcome-based evidence for trauma informed care for people with schizophrenia. There were no controlled trials, nothing in the way of any standard study of anything related to trauma informed care.

Yet education about this recovery movement and treatment approach is being mandated by our state government. There's something seriously wrong here. An intervention with no evidence base is being required and weighed on the same level as a requirement for CPR certification.

The trauma recovery and prevention movement also has moved into the domain of disaster psychiatry. This is the idea that prompt mental health intervention can prevent longterm psychiatric complications for people who experience traumatic events. I've written about this before on the blog in my posts "I Don't Need to Talk" and "I Still Don't Need to Talk", including a review of studies to suggest that for some people these interventions may actually be harmful. In his Mental Illness Policy blog, DJ Jaffe expressed similar concerns in his post "NYS Office of Mental Health: Wrong Response to Hurricane Sandy," where he discussed the diversion of mental health workers to crisis counseling and away from services for the seriously mentally ill.

Government money for mental health services is limited, and should be directed toward people with serious mental illnesses and evidence based practices.

Sandy

So, I've been taking a little break while ClinkShrink posts about the AAPL conference.  I always enjoy hearing about what she's learned there.  We both had the pleasure of being in the sky last weekend as we awaited the arrival of Hurricane Sandy, though my flight, the only one heading to the East coast from Milwaukee that was not cancelled,  did not include unscheduled stops in the wrong part of the country.  Clink and I were both pleased to get home, and even more pleased that our region was spared the brunt of the storm.  In 1999, a large tree fell on my house during Tropical Storm Floyd, and I've never liked storms since then.  If there's a post-traumatic tree disorder, I have it. 

So Seaside Height, New Jersey is a place I remember from my childhood.  The day I got my drivers' license, I drove two miles to a friend's house.  She and another friend jumped into the car and said, "Let's go to the beach."  Now I had been a licensed driver for six hours, and we didn't live near the beach.  "No," I said, "too far."  "Oh, come on."  Why not.  We drove to Seaside Heights, played games on the Boardwalk, and drove home.  No cell phones back then.  I dropped my friends off and returned home around 1:30 in the morning (no laws requiring midnight curfews back then, either).  I walked in and my mother greeted me with, "I was so worried, I thought you'd been caught in a flash flood."  Flash flood?  What flood? "It rained," I said.  She stopped and said, "Where were you?"  Ah, obviously someplace where it hadn't rained.  I like that memory and I don't like seeing photos of the rides in the water.  

To all those who are still feeling the effects of the storm, our hearts go out to you.

Thinking About Bellevue

Little did I know as I was writing that last post on Sunday that just a few days later some of the same docs I was listening to and learning from would end up evacuating their hospital. When I read about the desperate conditions at Bellevue Hospital in New York as the storm struck and the remarkable efforts to evacuate every one of those hundreds of patients---without any loss of life, to my knowledge---I was impressed and humbled.

Every hospital and institution theoretically is supposed to have emergency policies and procedures, and is supposed to run occasional disaster drills to make sure everyone is aware of them, but who ever really believes they'll be needed or used? Those kind of large scale, potential mass casualty events seem to horrible to think about or really imagine could happen. Until they do.

There's not much I can do from a distance, but from my brief contacts with the Bellevue docs I know that those seriously mentally ill patients and prisoners received the best care possible under the worst possible conditions.

Let's hope that when the storm clouds clear and the rubble is swept away, the hospital that re-emerges is a newer, better and brighter one. The patients and staff deserve it.
----------------
Addendum from Dinah: there is an article on the Bellevue evacuation here. 

Bariatric Weight Loss Surgery and Low Calorie Diet for Diabetes 2

Can Bariatric Weight Loss Surgery Control Type 2 Diabetes Mellitus? Cleveland Clinic Declares Bariatric Surgery as a Top Medical Innovation

Many diabetes experts now believe that weight-loss surgery should be offered much earlier as a reasonable treatment option for patients with poorly controlled diabetes. Also in a related development scientists in England have reported treating type 2 diabetes with extreme diet.

What is the difference between diabetes Type 1 and Type 2?

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Type 2 Diabetes, which tends to be the kind people get when they are in middle age or older usually is a problem more with so called insulin resistance where the cells aren't responding efficiently to the insulin (rather than as in Type 1 where there is a deficit of insulin) although it's not quite that clear cut and people do get insulin injections sometimes even for Type 2 Diabetes.

Have gastric bypass surgery. Lose your diabetes? Could it be that simple? There is evidence that gastric bypass surgery can help people with type 2 diabetes to the degree that the Cleveland Clinic put bariatric weight loss surgery on their list of the top 10 medical innovations of 2013. The benefit of gastric bypass surgery for some people with diabetes may derive from more than just the simple weight loss.

What is the evidence that weight loss surgery can help diabetes type 2?

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According to a past article in the LA Times, "As many as 86% of obese people with Type 2 diabetes find their diabetes is gone or much easier to control within days of having weight-loss surgery, according to a meta-analysis of 19 studies published earlier this year in the American Journal of Medicine (78% of patients with a remission of diabetes and 86.6% with remission or improvement). But experts still aren't sure why obesity surgery helps resolve Type 2 diabetes or how long the effect might last. And they disagree on how big a role surgery should take in treating the illness."

Have Bariatric Weight Loss Surgery Lose Type 2 Diabetes Could It be That Simple?

healty medical Blog had written previously about another study called Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes. Researchers divided obese people with Type 2 diabetes into two groups. One group of obese diabetics got weight loss surgery, laparoscopic adjustable gastric banding and the other group of diabetics got conventional diabetes therapy with a focus on weight loss by lifestyle change. The researchers found that "participants randomized to surgical therapy were more likely to achieve remission of type 2 diabetes through greater weight loss. These results need to be confirmed in a larger, more diverse population and have long-term efficacy assessed".







Video Says Gastric Bypass Might Improve Diabetes









"The study, of 60 patients, showed that 73 percent of those who had the gastric banding surgery had complete remissions of diabetes, meaning all signs of the disease went away. By contrast, the remission rate was only 13 percent in those given conventional treatment, which included intensive counseling on diet and exercise for weight loss, and, when needed, diabetes medicines like insulin, metformin and other drugs". Type 2 diabetes is the more common form of diabetes. Doctors have known for some time that weight loss tends to improve Type 2 diabetes. It tends to appear in older people and can be due to a lack of sensitivity of the insulin receptors in the body. Type 2 diabetes is more likely to be treated with pills than insulin shots.

Click healty medical Study Suggest Less Cancer With Gastric Bypass

Click Here for Risks Rewards Gastric Bypass Weight Surgery



The Times article writes "There is strong evidence that surgery -- especially gastric bypass surgery, which makes the stomach smaller and allows food to bypass part of the small intestine -- causes chemical changes in the intestine, says Dr. Jonathan Q. Purnell, director of the Bionutrition Unit at Oregon Health & Science University. The small intestine has been thought of simply as the place where digestion occurs".



"But researchers now suspect it has other functions related to metabolism. (Gastric Bypass) surgery somehow alters the secretion of hormones in the gut that play a role in appetite and help process sugar normally".

BRITISH RESEARCHER AT DIABETES MEETING SAYS RADICAL DIET MIGHT GET RID OF DIABETES MELLITUS TYPE 2 AND VIDEO ABOUT DIABETES

Cleveland Clinic: Top 10 Innovations announced

Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes

Gastric bypass: Is it a diabetes fix?

Diabetes Study Favors Surgery to Treat Obese

What I Learned Part 4

This is a belated post about the AAPL conference, since yesterday was devoted to finding my way home around Sandy. It's rainy heavily here and the wind is starting to pick up a bit. Dinah's at home waiting for a tree to fall on her house but there's no word from Roy. I'm hoping all our readers are home safe and prepared.

The last day of the conference was worth waiting for. I regularly attend the presentations given by the Computers in Psychiatry committee, and this year was no exception. Two presenters had to leave early due to the storm, but the remaining members talked about how to do Google power searches (using conjunctive and disjunctive search terms and site-specific searches) and other non-Google search engines (there's something other than Bing?). There was also a presentation about a wide variety of health care related smart phone apps. As yet, the FDA does not regulate these as medical devices and there is no standard method for assessing accuracy, efficacy or reliability. For those docs "prescribing" or recommending apps, there was discussion about whether or not the use of apps is becoming a standard of care for medicine and at what point there may be liability for their use---not following up on an app "flag" for instance. I was pleasantly surprised to see that one of the first psychiatry apps mentioned was "What's My M3?", a project that Roy has been affiliated with. (Maybe Roy might want to right a post about the standard of care and liability issues I mentioned? I'm sure this has been discussed and I'm curious.)

The last session of the day was about assessment of stalkers. I learned that three-fourths of more than 400 Canadian politicians had experienced an overt threat. When assessing risk, the assessment considers both the stalker and the situation. The three main considerations are level of persistence, risk of injury to the target and the potential for recurrence if the stalking has stopped or interrupted. The most persistent stalkers are those with psychotic illnesses, specifically delusions. Grandiose or erotomanic stalkers are less likely to present a risk of danger since they are seeking intimate contact rather than violent contact. People with paranoid delusions who are also angry are more likely to present a risk of violence. There's a lot more to these assessments, but those were the highlights that I took away.

That was the last session of the conference. I confirmed my flight as I left the hotel, but by the time I got to the airport checkin desk it was cancelled. Such is the risk of the AAPL conference. Last year at this time in Boston we were facing an impending snowstorm.

If you're in need of more conference fixes, I'd recommend the Child Sexual Abuse Conference (hashtag #CSAC12 on Twitter) which is live-streaming some talks.

Brains Scans Show Physical Activity Protects Brain

Scientists: Brain Imaging Suggests Physical Activity May Protect the Brain Especially the Brain of Older People

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What did the brain scans of active people show?

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Edinburgh scientists said they saw evidence on brain scans that physical activity kept people's brains in better shape. They looked at older people who did physical activity such as long walks several times a week to see if activity affected their brains. The scientists report in the journal Neurology that they looked at more than 600 people in their 70's.

What did the brain scans study of active people conclude?

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The brain scans of the walkers showed less atrophy, shrinkage and better white matter integrity. They concluded "In this large, narrow-age sample of adults in their 70's,physical activity was associated with less atrophy and white matter lesion. It's role as a potential neuro protective factor is supported: however, the direction of causation is unclear from this observational study."

Neuroprotective lifestyles and the aging brain
Activity, atrophy, and white matter integrity

What I Learned Part 3

Oh my...I still have one more day to go at the conference and my brain is already full.

The award for Weird Presentation of the Week (and that's saying a lot at a forensic conference!) goes to the poster on zoophilic interests in cases of Asperger's syndrome. I'll say no more about that. Just make sure you know who's petting your dog.

Another poster was an interesting case presentation about sleep apnea and anger and hostility. Apparently treatment with continuous positive airway pressure therapy has lead to significant improvement in irritability for sleep apnea sufferers. You might want to read a little bit about previous research on this here.

I enjoyed a panel discussion about ethical issues in forensic evaluations, particularly as it related to interviews of collateral informants. Although non-confidentiality warnings are routinely given, there is still the possibility that an informant may volunteer self-incriminating information or information that falls under a mandatory reporting duty.

Unfortunately, our luncheon speaker was held up in Tennessee and couldn't make his talk. I was looking forward to listening to Jon Ronson, author of The Psychopath Test. Instead we heard a talk by Dr. Phil Resnick about the relationship between paranoid delusions and violence. In addition to hearing a number of good anecdotes, we learned that delusions are more highly correlated with violence than command hallucinations.

The best session of the day was a panel presentation about false confessions. This has always been an interest of mine, but I've rarely had the opportunity to hear the people who have done the original research. I learned a lot about the Reid technique, including which techniques are commonly used and how the techniques are varied depending upon the presence of mental illness. I learned that of people exonerated by DNA, 16% had given detailed confessions. Overall, 80% of defendants waive their Miranda rights. In Canada, interrogations don't have to end when a defendant asks for a lawyer or when he claims his right to avoid self-incrimination. One panelist presented the results of a survey of 332 Baltimore County police officers regarding their understanding of juvenile development and their use of interrogation techniques. The survey showed that even though they understood the developmental differences between juveniles and adults, their actual interrogation practices were no different.

I listened to a presentation about the new diagnostic criteria for antisocial personality disorder coming out in DSM-5. In a word: ugh. Don't ask me how people are going to interpret the "self-identity" and "self-direction" criteria. The requirement for childhood conduct disorder will be dropped. I'm predicting even greater diagnostic discrepancies than what we have now.

Finally, a group from West Virginia presented some background information about an ongoing survey project regarding the use of social media in forensic evaluations. There wasn't a lot of data available yet because many of the forensic fellows had not received the survey (it was sent to all program directors and their students). Social media use by forensic healthys was not directly correlated to age. Both early and late career forensic healthys used it. There was a good overview of how social media content could be used in both civil and criminal cases. During the question session I added a comment about social media use in medical education as well.

Tomorrow is the last day, then I make my way back through the storm (or hopefully, ahead of the storm). Wish me luck.

What I Learned Part 2

Oh my, it's hard to keep my mind on professional things when I see a hurricane headed toward my home. The airline says they're not expecting it to affect my flight back, but I'll believe that when I see it.

But on to the conference...

The poster session was notable for a nice outcome study done in Georgia about the efficacy and cost impact of a jail-based competency restoration program. Another poster about assisted outpatient treatment in New York showed that there was considerable variation in willingness to seek outpatient commitment, possibly related to available outpatient services. There was a presentation about the use of restraints in pregnant psychiatric patients which was interesting. There was a national survey of mental health program directors which showed that up to 80% of responding systems had no established policy about this.

There was a panel presentation about the AAPL guidelines for sanity evaluations, which are being updated. Members were given the opportunity to comment upon the current guidelines and any issues that needed to be revised.

I was pleased to see ethics featured prominently at this conference, including a very informative panel presentation about the process by which AAPL and APA manage ethical complaints and the difficulties writing and enforcing professional guidelines. I learned that about 10 to 15% of ethical complaints to APA district branches are related to forensic issues.

The luncheon speaker was David Kaczynski, brother to the infamous Unabomber Theodore Kaczynski. He gave a very moving talk about his early life with his older brother, Kaczynski's gradual withdrawal from his family and society in general, and the slowly growing realization that his older brother was indeed a killer. He talked about his struggle to come to terms with his suspicions, the impact on his elderly mother and what it felt like to be caught between preventing future murders and potentially sending his brother to a death sentence. He talked about his work after the trial, reconciling with some of the victim's families. My most memorable quote: "Teddy's bombs destroyed lives, but healing is possible."

The early afternoon session was a smorgasboard of random topics. There was a survey of judges regarding their willingness to allow defendants to represent themselves at court (pro se defenses). Judge weight heavily the defendant's ability to understand the risk of a pro se defense and the defendant's willingness to accept standby counselor. Psychiatric input is considered, but mainly as it related to a description of symptoms and impairment rather than the ultimate opinion of competence. There was a description of a telepsychiatry program used in the New York prison system, where fourteen facilities used teleconferencing to provide over 12,000 patient contacts in one year.

Finally, the secondary them of this conference appears to be the use of psychological tests by healthys. The last session of the day was entitled "Psychology vs Psychiatry in Risk Assessment". The panel presented individual cases and general principles related to the use of violence prediction instruments and how they are currently used in forensic work. The limitations of these instruments were also discussed, which was interesting because this is not something that often gets discussed by those who use them (at least in my experience). One example of this was the use of a violence risk instrument for conditional release. Since the risk of dangerousness must be due to a mental illness, and since the instrument did not rely upon illness-based dangerousness, the instrument was not relevant to the legal question at issue.

So that was the day. You can follow my live tweets from the conference at: www.twitter.com/clinkshrink

What I Learned Part 1

Those of you who have been reading the blog for a while know that every year I blog and live-tweet from the American Academy of Psychiatry and Law conference. This year we are hosted in Montreal, the land of fine dining and the most beautiful language in the world. Thus, the foodie picture. When I fly back I will be carrying extra baggage and I don't mean my luggage.

The poster session this morning was quite crowded and I wasn't able to get near most of them, but I did see a lot about legal and clinical implications of synthetic marijuana. Forty-one states have laws criminalizing sale and use of these new chemicals which go by a variety of street names. Effects on mental state can be extreme, including disorganized and violent behavior and hallucinations. So far there are no known longterm clinical effects associated with its use, however. Intoxication has been used in criminal defenses to mitigate culpability (although not generally successful as the basis for an insanity defense) and in states where the substances are still legal courts are struggling to figure out how it should play into a mental state defense.

Dr. Charles Scott gave an outstanding presidential address entitled "Believing Doesn't Make It So: Forensic Education and the Search for Truth." He discussed the evolving---and higher---expectations for forensic evidence, including psychiatric testimony, and how this should inform forensic training and practice.

The next session was a very nice (if I do say so myself) panel presentation about civil commitment of mentally ill offenders following release from prison. California has a mandatory civil commitment law which requires transfer of certain violent offenders with serious mental disorders to a psychiatric hospital at the end of incarceration. Legal challenges to this law were discussed and compared to the New Jersey system, which uses a non-mandatory administrative procedure instead. Finally, these procedures were compared to the state of Maryland where there is no established transfer policy but a wide degree of consultation and collaboration between the correctional and mental health systems, which in many cases obviates a need for hospital transfer.

[At this point in the day I stepped out for lunch and came back four courses later. Oh my, the food was amazing.]

The afternoon session was a very practical panel presentation about who should get access to forensic reports and the implications of HIPAA on evaluee access to protected health information in the report. Historically forensic reports were considered legal work products rather than medical documents, and as such an evaluee did not necessarily have a right to get a copy of or read the report. Under HIPAA some types of reports---such as a disability evaluation or fitness for duty evaluation---might be considered to be protected health information which an evaluee has a right to access. This is an evolving area, however. And under HIPAA, evaluees do not have a right to reports generated for civil, criminal or administrative hearings. This isn't a settled issue and there was good audience discussion.

The evening session was a mock trial which presented the new DSM 5 proposed criteria for hebephilia. The limitations and implications of the new criteria were discussed, which appeared to rely heavily upon an assessment of the victim's Tanner stage. The issue was presented in the context of a fictional sex offender civil commitment hearing, with three mock experts: one for the state, one for the defense, and one independent court-appointed expert. A strong case was made against inclusion when the defense expert testified that the new criteria could result in an 80 percent increase in false positive diagnoses.

So that was the first day. More to come so stay tuned. Live-tweets can be followed at: www.twitter.com/clinkshrink. [For those concerned about speakers' informed consent for social media coverage, all presenters are advised at abstract submission that sessions are recorded and they know that sessions may be covered by the media.]

Guest Blogger Dr. Meg Chisolm on Systematic Psychiatric Evaluation

Over on our Clinical Psychiatric News blog, I've written a review of a new book, just published by Johns Hopkins University Press, Systematic Psychiatric Evaluation,  A Step-by-Step Guide in Applying The Perspectives of Psychiatry, by Margaret S. Chisolm, M.D. and Constantine G. Lyketsos, M.D., M.H.S.  Do check out my review over on CPN (it should be up later today), along with ClinkShrink's article on "Debunking The Mad Artistic Genius Myth" and Roy's piece on World Mental Health Day which lists some great resources. 

Dr. Chisolm was kind enough to write a Shrink guest post for us on her inspiration for writing the book, with just a little about French cooking.  Sorry no recipes here.  Meg writes:

I did my psychiatry residency training at Johns Hopkins University in the late 1980s, under department chair Paul McHugh and residency director Phillip Slavney.  These leaders also are the authors of the textbook The Perspectives of Psychiatry, whose principles informed the way I and a generation of Hopkins healthys since have been trained.  The basic idea of The Perspectives is that by conducting an evaluation that considers a patient’s psychiatric presentation from each of four perspectives, the clinician can better understand the nature(s) and origin(s) of the patient’s problems, and develop a more comprehensive and personalized formulation and treatment.  (The four perspectives are: disease, dimensional, behavior, and life-story.) 

The most frequent question raised about the Perspectives model by trainees and clinicians unfamiliar with the approach is “How are the Perspectives any different from Engel’s biopsychosocial model?”  In response, McHugh and Slavney are fond of saying that the biopsychosocial model provides the ingredients (atoms to biosphere) for understanding patients with psychiatric illness, but the Perspectives provides the recipe.  I like this analogy (or is it a metaphor?) because, in addition to enjoying my work as a healthy, I like to cook.  But, more about that later. 

As a Hopkins-trained healthy, I had probably read The Perspectives of Psychiatry about five times, beginning with my stint as a medical student during my sub-internship at Hopkins.  Let me tell you, The Perspectives is a good, but hard read.  As a student, I don’t think I understood much of it.  Reading it again as a psychiatry intern, having seen many more patients with psychiatric conditions, it started to make some sense.  As a junior resident, I began to understand it a little better, which was a good thing since – by then – I was expected to be teaching the book to medical students.  By the time I was a chief resident teaching junior psychiatry residents how to apply the Perspectives approach to patients, I thought I had it down.  Well, I was wrong.  It wasn’t until I began writing a casebook companion to The Perspectives of Psychiatry that I finally figured it out.  So, if the biopsychosocial method provides the ingredients and The Perspectives of Psychiatry the recipe, that’s one highfalutin’ cookbook!  And that’s where our new book Systematic Psychiatric Evaluation: A Step-by-Guide to Applying ‘The Perspectives of Psychiatry’ (Chisolm & Lyketsos) comes in.

So, back to French cooking.  If any of you are into cooking, reading cookbooks, or just watching the Food Network, you may have heard of Auguste Escoffier’s 1903 Guide Culinaire.  Escoffier wrote his book for professionally trained and experienced European chefs (working in restaurants, hotels, ocean liners, private estates, etc).  Escoffier’s book outlined recipes and discussed methods of professional food preparation and kitchen management.  Escoffier did not offer his reader detailed recipes with instruction on basic cooking techniques, as he assumed the reader would already have this set of knowledge and skills.  His book’s target reader was not the average home cook looking for advice on how to keep a soufflé from falling.  Enter Julia Child and friends.  In Mastering the Art of French Cooking Julia Child et al translated a selection of Guide Culinaire recipes into simple steps and added detailed instruction on the basic techniques (How do you keep a soufflé from falling?  Ask Julia).  Julia Child’s goal was to start someone off in French cooking with the hope that someday they would be ready to go deeper and perhaps read the master himself. 

And so it is with Systematic Psychiatric Evaluation.  If you’re a clinician who already conducts a systematic psychiatric evaluation and are adept with applying the Perspectives approach to patients, there’s no need to read our book.  But, if you are new to the Perspectives and/or want to familiarize yourself with the model, we’ve got you covered.  Systematic Psychiatric Evaluation walks the reader through the basic concepts of The Perspective of Psychiatry and shows, step-by-step, how to apply these concepts to evaluate, formulate and develop individualized treatment plans for patients with psychiatric conditions.

Bon appétit!

Head Concussion Sports Injury You Don't Need a Head Hit

Concussion and Head Injury in Sports Concussion Even Without Head Hit: In 1904 Theodore Roosevelt Threatened to Ban Football

Children's Football Game Latest Spark to Ignite Sports Concussion Controversy

The NY Times had a shocking article about a little league football game where 5 concussions were diagnosed and yet the game went on. The repercussions from that game are still reverberating. "The debate the game has further fueled is not likely to calm any time soon. Head injuries in the National Football League remain the league’s greatest safety concern, and the league’s greatest legal liability".

"Ivy League universities have ordered limits on contact in practice, to reduce the risk of brain injuries. And Pop Warner, the national organization made up of hundreds of thousands of children, some as young as 5, has adopted its own safety guidelines, based in part on the medical wisdom that the brains of young boys are particularly vulnerable".

A head concussion is one of the most prominent of sports injuries. Diagnosis requires a high degree of suspicion when you suspect an injury. Concussion is a disturbance in brain function. It can be caused by an indirect or direct force that results in shear stress to the head. You don't need to get hit in the head to have a concussion. Brain injury can happen by rotation or angular force. In 1904, President Theodore Roosevelt threatened to outlaw football after 19 college football players were killed or paralyzed from brain or spinal cord injuries.





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You may or may not pass out. Even though the brain is surrounded by cerebrospinal fluid, protected by the skull and cushioned by the meninges i.e. the linings of the central nervous system, the impact of a concussion can cause brain damage and repeated concussions can cause cumulative damage to the brain.









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"It’s true that coaches have become better educated about concussions. The days of patting the athlete who’s had his “bell rung” on the backside and sending him back into the game are diminishing. Most now realize that someone who’s had a concussion needs rest. He or she may need to take a break from the sport, or even from school. This allows the brain to devote all its resources to healing".

A 5-Concussion Pee Wee Game Leads to Penalties for the Adults

Head Games Concussions

healty medical Blog Vince Lombardi Was Right

National Center for Catastrophic Sport Injury Research TWENTY-FIFTH ANNUAL REPORT FALL 1982 - SPRING 2007

How Has Psychiatry Changed: On National Public Radio

 




Our blogger friend, Steve who writes on Thought Broadcast, was on Talk of the Nation yesterday to discuss trends in psychiatric treatment.  If you didn't get a chance to listen, I'm taking the liberty of embedding the interview here.  Steve did a great job!

Okay, Steve, time to get off Facebook and write another blog post, it's been a while!

Podcast #69 : Partnering WITH Patients

Here are the topics we discuss on this fine evening at Roy's house:

• What does "Shrink Rap" mean (reader request)?

• Roy talks about an "amazing" conference he went to called Partnership with Patients.  This conference was started by Regina Holliday, patient-advocate-extraordinaire. Here are some links for things that caught his attention:
• HealthCamp: http://HealthCa.mp/kansascity
• http://partnershipwithpatients.com/
• Donate to Patient Pod at Medstartr at http://bit.ly/patientpod where Pat Mastors is trying to raise $4200 by Oct Nov 20 (oops, we missed that deadline) (the date was extended... please help fund the project. ~Roy).

•  Clink talks about a Massachusetts legal case regarding gender reassignment of prisoners

• And finally, we talk about a reader's question about how and why patients test their therapists/healthys.

      

• This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 
  
  Thank you for listening.
  Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post.
  To review our podcast, please go to iTunes.
  To review our book, please go to Amazon.

Kids and Mental Illness

I try to stay out of the whole Kiddy Bipolar Debate debate: none of the Shrink Rappers see children, so my knowledge of childhood psychiatric disorders is limited to what I saw during a 3 month inpatient rotation 20 years ago, what I read, and what I see of children in my personal life.  It's a messy topic.  

I brought it up today because the Wall Street Journal has an article that summarizes nicely all the issues, the issues with regard to diagnosis, the fear of over-treating, the problem with under-treating, the question of whether mood dysregulation in children should be a separate disorder.  Please see Shirley Wang's article The Long Battle to Rethink Mental Illness in Children. 

I'm glad they're leaning towards renaming bipolar disorder in children.  When you hear Bipolar Disorder, you think about a lifelong condition that requires medication forever.  Children have phases, behaviors occur in some arenas and not others.  Perhaps if a child's emotional life is intolerable to them, or their behaviors make it impossible to function in their worlds, it's worth the risks to administer medications.  But a kid throwing horrible tantrums, fighting, running around the room, does not necessarily evolve into the same category as an adult who has 3 episodes of depression, and 2 episodes of psychotic mania, during their lifetime.  Oh, and I'm the one who thinks we should Rethink all of the Bipolar Diagnosis, not just for kids. 

So Wang writes: 

At one of his group's first in-person meetings, the NIMH's Dr. Leibenluft, an expert on bipolar disorder in children, gave a 20-minute PowerPoint presentation with evidence for a potential new disease. She called it Severe Mood Dysregulation.
She described a decade of studying children with severe mood problems that don't fit neatly into current illnesses. Thus began a cerebral process to decide what these kids might be suffering from.
The two main options: Create a new disease, or create a variant to an existing disorder. The discussions ran for years.

How Would You Fix the World?

Ah, our candidates have been debating, and everyone has a fix for society's woes.  Romney has an easy plan: cut taxes, this will let businesses keep their money so they can hire more employees, create more jobs (he has the precise number, even) and help the economy grow and everything will fall into place.  If we cut funds to Medicaid, Medicare, undo ObamaCare, and fire Big Bird, then we'll be able to pay off the trillions of dollars of National Debt, all while growing the military, and all will be well.  I know, I'm exaggerating, and it really isn't clear that cutting government funds to public television would mean the demise of Ernie & Bert.  Obama -- I'm not sure what his plan is to save the nation, but whatever it is (? more of the same), it's probably not going to lower the national debt.  It seems we live in a place where our expenses exceed our income.

I don't want to use this as a soapbox to express my political views or to influence your vote, instead I want to tell you that sometimes I have fantasies about how I would fix the world.  Actually, I have a lot of them.  I thought I would tell you my main thought, and ask you to tell me yours.  I'm a doctor, I've never taken a single econ or poly sci course in my life, so please be gentle with me.  It's just a fantasy.  And I won't make fun of yours.

So here's my thought, and unfortunately, it would entail more spending by the government.  I would like to see public schools mandated to have class size limits, preferably to 10-12 students, for certain grades, in any area where poverty levels are high, crime and drug use is a problem, and graduation rates are low .  I'd like to see the class size brought down for either first or second grade so that each student could get intensive, individualized education so that as many children as possible would get a good start with being able to read, because once they fall behind here, they're lost forever.  I'd like to see school days be longer and include some time on the weekend. It doesn't need to be all grind and work: wouldn't it be great to include an hour a day of sports and exercise for children in poverty regions where obesity rates are highest?  And games (Scrabble, anyone?), music, and ideally a bit of immersion in a second language?  It would be very expensive: more teachers (oh, and more jobs for teachers...), more classrooms (oh, and more construction jobs to build the classrooms), more resources all around.  And longer days would give children a chance to do their homework in school, provide child care so that their parents could work and have more disposable income, and keep the children out of drug-ridden, dysfunctional environments.  (I'd be fine with having the extended day segment be optional).  Oh, and Head Start has tried such things and the children make gains, but they only last for 3 years.  Okay, so look at the school curriculum and figure which years are the most crucial in maintaining a student's success, and shrink the class size for a few other years.  Maybe we make sure everyone is able to read and do basic arithmetic by the end of 2nd grade, and make sure everyone can write book reports and simple research papers, manage money and measurements, know a little about science,  how to read a newspaper, keyboard, use technology,  and start to think critically in 5th grade.   Too expensive, you say?  And I would counter with Really?  It would entail putting much more money into education, and making sure it goes to direct child-centered resources, like teachers and books, and not towards more administrators, or more standardized tests.

  So how does this fix the world?  Well, perhaps if we can impact these children early, they will be in a better position to succeed later, they will have feel more self-confident and won't view selling drugs as the only way out of poverty.  They will be more employable, and more likely to contribute, rather than drain, resources.  And perhaps if just a few less children from every class end up in jail, that could pay for my plan.  We hear outcries about public spending, and certainly, in wealthier areas where children do fine in classes of 30, there would be an outcry that their children should have smaller classes, especially since they are paying more taxes, but those same people don't object to spending $25-50,000 a year of their taxpayer's money to house those same children in jail when they grow up to be criminals.  

Thanks for indulging my fantasy.  I would love to hear your plan for fixing some of our problems. 

Could Vitamin D Supplementation Lower Breast Cancer What about Marin County

What Does Vitamin D Have to do with Breast Cancer Could Vitamin D be Related to Breast Cancer in Marin County, California

Crossing the Golden Gate Bridge from San Francisco you have the bay on your right, the ocean on your left and Marin County before you. Marin may have some of the "hippest" people and prettiest scenery around but researchers have long been trying to determine why largely white, affluent Marin County also has a higher than average rate of breast cancer.

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Studies Point to Some Relationship Between Breast Cancer and Vitamin D but What

There seems to be some relationship between Vitamin D and breast cancer but what that is has not been made clear. Women with low vitamin D levels may have an increased risk for the most aggressive breast cancers,research suggests.

Several studies have suggested a link between low vitamin D levels and breast cancer risk. Back in 2008, a report from Toronto researchers concluded "Vitamin D deficiency is common at breast cancer diagnosis and is associated with poor prognosis". Also researchers from the University of Rochester Medical Center examined vitamin D levels in 155 breast cancer patients in the months before or after they had surgery to treat their disease. They found sub optimal vitamin D levels to be highly predictive of the presence of biological markers associated with more aggressive tumors.



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What Does Marin County have to do with Vitamin D and Breast Cancer

In the case of Marin, a small pilot study of women determined through testing to be at high risk for breast cancer, found them to be almost twice as likely to have a variant of a vitamin D receptor as the overall population of 338 in the study. The study concluded "The high frequency of the VDR Apa1 A2/A2 homozygous polymorphism in women designated as elevated risk for breast cancer by the polyfactorial risk model might be related to the high incidence rates of breast cancer in Marin County, CA. Vitamin D supplementation could modify risk of breast cancer in this population."







According to BreastCancer.org "Research suggests that women with low levels of vitamin D have a higher risk of breast cancer. Vitamin D may play a role in controlling normal breast cell growth and may be able to stop breast cancer cells from growing".

Marin County’s High Breast Cancer Rate May be Tied to Genetics

Frequency of vitamin D deficiency at breast cancer diagnosis and association with risk of

The association between breast cancer prognostic indicators and serum 25-OH vitamin D levels.

Low Vitamin D levels and Breast Cancer