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

Lycopene Benefits Study Says People Who Had More Lycopene had Less Strokes Also What about Lycopene and Cancer

Less Strokes with Lycopene? Also What Benefits if any of Lycopene for Cancer

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Could eating tomatoes help prevent strokes?

A Finnish study suggests that high blood levels of lycopene, unlike those of other antioxidants, may be associated with a significantly reduced risk of stroke. Vegetables, especially tomatoes, are a significant source of lycopene.

The study published in the journal Neurology concludes "This prospective study shows that high serum concentrations of lycopene, as a marker of intake of tomatoes and tomato-based products, decrease the risk of any stroke and ischemic stroke in men".

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Intake of fruits and vegetables and levels of serum carotenoids have been associated with decreased risk of stroke, but the results have been inconsistent. The aim of the present study was to examine whether serum concentrations of major carotenoids, α-tocopherol and retinol, are related to any stroke and ischemic stroke in men. The analysis, published in the journal Neurology, prospectively followed 1,031 men ages 46 to 55, measuring their blood levels of five antioxidants and recording incidents of stroke.







Lycopene a chemical which is found in tomatoes has also been touted as a possible agent to lower cancer risk. According to the American Cancer Society "Studies that look at large groups of people (observational studies) in many countries have shown that the risk for some types of cancer is lower in people who have higher levels of lycopene in their blood. Studies suggest that diets rich in tomatoes may account for this reduction in risk. Evidence is strongest for lycopene's protective effect against cancer of the lung, stomach, and prostate. It may also help to protect against cancer of the cervix, breast, mouth, pancreas, esophagus, and colon and rectum".







Some population studies have found that a diet high in lycopene from tomato-based foods was linked with a lower risk of prostate cancer. Other studies, however, found no link between tomato products or other lycopene-rich foods and prostate cancer. A recent study suggested that variation in a particular gene (known as XRCC1) that helps repair damaged DNA influences whether lycopene intake will affect a man's prostate cancer risk.

Serum lycopene decreases the risk of stroke in men

ACS on Lycopene and Cancer

Do Young People Get Strokes

One Dad's Perspective

Okay, while our presidential candidates are debating, I thought I would link to an article by a former state legislator.  In "How I Helped Create a Flawed Mental Health System That Failed Millions -- and My Son," Paul Gianfriddo talks about his decades-long attempts to help his ill son, a young man who sounds to have mental health and educational needs that couldn't be met by a system with limitations.

Gianfriddo writes:

The 1980s was the decade when many of the state’s large psychiatric hospitals were emptied. We had the right idea. After years of neglect, the hospitals’ programs and buildings were in decay. But we didn’t always understand what we were doing. In my new legislative role, I jumped at the opportunity to move people out of “those places.” Through my subcommittee, I initiated funding for community mental health and substance abuse treatment programs for adults, returned young people from institution-based “special school districts” to schools in their hometowns, and provided for care coordinators to help manage the transition of people back into the community. 

But we legislators in Connecticut and many other states made a series of critical misjudgments that have haunted us all ever since. 

First, we didn’t understand how poorly prepared the public school systems were to educate children with serious mental illnesses in regular schools and classrooms. Second, we didn’t adequately fund community agencies to meet the new demand for community mental health services—ultimately forcing our county jails to fill the void. And third, we didn’t realize how important it would be to create collaborations among educators, primary care clinicians, mental health professionals, social services providers, and even members of the criminal justice system, if people with serious mental illnesses were to have a reasonable chance of living successfully in the community. 

During the twenty-five years since, I’ve experienced firsthand the devastating consequences of these mistakes.

The story about his son is heart-breaking and there is no happy ending.  I'll leave you to read the whole article and see what you think.  And if you'd like to check it out, Mr. Gianfriddo blogs, often about mental health issues, at Our Health Policy Matters.

What Doesn't Kill You Makes You Stronger

I wanted to share this with you -- I thought you might find Act 3 interesting.  It's about a woman with life-threatening OCD.  Act 3 starts just after the 36 minute point and lasts for about 15 minutes.

What Does Vitamin B12 Do and What are Signs of B12 Deficiency and How Treated

What Does Vitamin B12 Do Where Do You Get B12 and How is B12 Deficiency Treated?

Depression,Thinking and Memory Problems with B12 Deficiency

What are common nerve symptoms of B12 deficiency?

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B12 deficiency can include tingling, weakness, numbness, problems walking or thinking, depression or memory problems.







Can't you just get all the vitamins you need from food?

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Don't we make all the vitamins we need? The answer may be no and no. Vitamin B12 is essential for the body to create dna and is needed for neurological processes. B12 has a key role in the normal functioning of the brain and nervous system, and for the formation of blood. It is one of the eight B vitamins. It is normally involved in the metabolism of every cell of the human body, especially affecting DNA synthesis and regulation, but also fatty acid synthesis and energy production. Neither fungi, plants or animals are capable of producing vitamin B12.

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Can't We Make B12 ?

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Risk factors for vitamin B12 deficiency include older people, alcohol abuse, diabetics who take metformin, vegetarians,people with gastritis, crohn's disease,certain gastric bypasses,etc.



Since your body can't manufacture B12 you need to get it from someplace else by taking a vitamin or eating something that contains it.Vitamin B12 can be given as a shot and or taken as an oral vitamin. People especially older people and vegetarians may not be able to get enough vitamin B12 from their diet and may need B12 vitamin supplementation.



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The acid in the digestive system helps get the B12 out of meat that we eat. That is one reason that people who have certain gastritis or malabsorption have problems getting B12. People who use the drug metformin, a diabetes drug, need to be screened for B12 deficiency.

How Intense Should Blood Sugar Control Be in Type 2 Diabetes

How Intense Should Blood Sugar Control be in Type 2 Diabetes and How Do Doctors Measure Blood Sugar Control in Diabetes?

A Study Published in 2011 Said That While Blood Sugar Control is Very Important Very Intensive Glycemic (Blood Sugar) Control did not seem to Reduce Mortality Beyond a Shadow of A Doubt and was Associated with Severe Low Blood Sugar

Control of blood sugar in people with diabetes is very important.The American Diabetic Association “Standards of Medical Care in Diabetes” recommends lowering HbA1c to <7.

Doctors know that people with diabetes must work to keep their blood sugars normal and that high blood sugars are associated with eye, heart, kidney and circulation and foot problems. The billion dollar question is how low should sugars be?









Doctors searched the medical literature for studies of the benefits of very tight control of blood sugar. The idea is if tight control of blood sugars is known to be beneficial than maybe very tight control of blood sugar is even better. The doctors tried to combine the results of 14 studies with a technique called meta-analysis.

In this Large Meta-Analysis Intensive Glycemic Control Did Not Reduce Mortality and was Associated with an increased Risk of Severe Hypoglycemia

Their meta-analysis did not demonstrate beyond a shadow of a doubt that super intense control of blood sugars had these extra benefits and they did find evidence of dangerous low blood sugar (hypoglycemia).





"We found evidence to refute the suggestion that intensive compared with conventional glycaemic control reduces all cause mortality with a relative risk reduction of 10% or more. We found insufficient information to confirm or exclude a 10% relative risk reduction in cardiovascular mortality and non-fatal myocardial infarction with intensive glycaemic control. We found insufficient evidence for a reduction in risk of composite microvascular complications, retinopathy, and nephropathy. Conversely, we confirmed a 30% increase in relative risk of severe hypoglycaemia with intensive compared with conventional glycaemic control. Accordingly, treatment and choice of a glycaemic target for patients with type 2 diabetes need to take both harms and benefits into account."

Intensive glycaemic control for patients with type 2 diabetes: systematic review with meta-analysis and trial sequential analysis of randomised clinical trials

Falling: Faces of Depression and Anxiety (by Clara Lieu)

Clara Lieu is an artist at Rhode Island School of Design.

She has this amazing gift of observation. For example, she has this series on her website (claralieu.com) called Waiting. Here is how she describes it.

I am interested in the contradictions found in waiting figures: even though these figures stand in very close physical proximity to each other, it seems apparent that there is a significant emotional distance between them. Each figure seems locked within their own existence, unaware and unresponsive to the other figures surrounding them. Yet simultaneously, waiting in a line creates a situation where the gesture of one figure leads directly to the next, creating a fluidity between all of the figures. I am engaged by the individual and group anxiety that seems to permeate such silent and still scenes.

So true. My first iPhone line was like that.



She also completed a very impressive series of drawings and sculptures called Falling. This series, unlike her others, are very personal, based on her own experience with depression.

She emailed My Three Shrinks to let us know about her work. I was so impressed that I asked her more about herself and the motivation to show such an intimate view of her anguish.

I developed depression and anxiety at a young age, and lived with the condition for most of my life before being diagnosed and treated just a few years ago. It was startling to see myself clearly for the first time, free from the disease. Only at that point did I have the emotional distance that allowed me to to be in position to address this subject artistically. I knew at that point that I felt an uncontrollable drive and compulsion to make the work.

"Falling" was an unusual project me for in that it was told from a very personal, intimate perspective unlike my previous projects, which approached the subject matter with an emotional distance. Depression is something that happens privately, behind closed doors; it's a secret that most people keep hidden and never talk about in public. Unfortunately here's still a social stigma associated with depression that causes people with depression to conceal their true emotions from others. On a broader level, I'm looking to open a dialogue about a topic that is rarely discussed openly by exposing my own personal experience. 

She goes on to describe this body of work:

"Falling" is a visualization of personal experience with depression and anxiety. The condition brought on frequent episodes where I felt emotionally and physically out of control. Unable to “release” myself from these episodes, I waited for the physical limitations of my body to end them. Recounting the affected years, I realize how accustomed I became to depression’s influence; many emotions and feelings belonged to it and not my own personality. After an extended, untreated struggle, a diagnosis brought relief, and the process of unearthing myself from the disease began. 

Her work can be found at claralieu.com.




Note: October 11 is National Depression Screening Day.       Get screened.

People Lose More Weight in Commercial Weight Loss Program

British Study Says People Lose More Weight in a Commercial Weight Loss Program like Weight Watchers, Rosemary Conley or Slimming World than by Counseling from their Doctors

File this in the stuff I didn't need a study to figure out department. A study that appeared in a British medical journal reported that people who joined a commercial weight loss program were more successful at losing weight than people who just got counseling from a doctor.

In the study several hundreds of over weight people in England were recruited into a study to see if people lost more weight when they got counseling from a primary care provider or if they joined a commercial weight loss group. The weight control groups were commercial weight loss programs in Great Britain such as Weight Watchers, Rosemary Conley or Slimming World. The primary care counselors were a doctor counseling someone on weight loss or pharmacy one to one counseling or a group from the British National Health Service called Size Down..

They looked at weight loss at 12 weeks and at one year. The most effective weight loss was in people who had participated in a commercial weight loss program. The least effective was someone who had just got counseling from a doctor.

Comparison of range of commercial or primary care led weight reduction programmes with minimal intervention control for weight loss in obesity: Lighten Up randomised controlled trial

Dinah is Mad

A few days ago, I posted a link to what I thought was a nice article in the New York Times about a special team of NYC police officers who talk people out of jumping off bridges and buildings, and even jump into the waters to fish them out.  The responses to the post and to my comments left me a bit distraught.  It's been a while since Shrink Rap has been this contentious, and it left me feeling rather defensive.  I tried to put up a response in the comment section, but my comment was too long, so I'm posting it as it's own post.

First, Sarebear, thank you.  She wrote:

"The range of human behavior, motivations, reactions to illnesses is huge. Just because it's not YOUR experience, doesn't mean it isn't valid as someone else's. Just because your experience isn't THEIR experience, doesn't make yours invalid either."

Brilliant.  Thank you.

To the assortment of anons who felt inspired to write in with:

"Yet again, I wonder if this is how you interact with your patients. How do you maintain a practice? Or do you perhaps see only the very mildly mentally ill, the slightly neurotic."  and " It's also surprising that both of you claim enough knowledge of suicide to present at a conference."

I think you should find other another psychiatry blog.  This is far beyond the realm of what one would say to someone in their living room, and the readiness with which you insult us is as though we are not human beings with feelings!  I showed this to my husband whose response was "I don't know why you do this and why you would interact with people this way." 

My comment on the damage suicide leaves in it's wake is a statement of fact.  One friend told me that she started to feel just a little better five years after her son's suicide.
A reader responded that my comment was "demeaning and insulting." " Of course every suicidal person has considered carefully, long and hard, the effect his or her suicide will have on his loved ones. The implication that they have never thought such a thing is really offensive." 
To the anon who wrote:
"Dinah, it sounds like you've never treated suicidal people. If true, it is surprising."
I have never treated a patient who has successfully committed suicide.  I have treated two patients who have had serious attempts while under my care, and many who have had serious attempt before they were my patient.  In general, a serious suicide attempt is reason change doctors -- it is a sign that the treatment is not working, and it destroys trust.

And while I have not treated many seriously suicidal patients, most people with depression have suicidal thoughts and feelings, different from what it takes to complete the actual act. On the rare days when the thoughts seem like anything more than thoughts, I have no qualms about telling my distressed patient that I would be devastated if they committed suicide.   

I can't count the number of people I have treated who have had relatives commit suicide, but it's a lot.  Should we start with the woman whose husband waited until she was coming up the walk to shoot himself in front of her? That began her long and involved time as a psychiatric patient.

No, it's not always thought out enough to be "selfish," (I never used that word) sometimes it's from psychosis, sometimes it's a teenager who can think of no other way to deal with heartbreak, sometimes it's an escape, other times it is the by-product of overwhelming depression.  It's still leaves generations of pain.

  Over 38,354 died by suicide in 2010, despite the best efforts of psychiatry, the NYPD jumper team, and the lack of mental health euthanasia teams.  That number doesn't count the suicides done in ways that medical examiner might have deemed accidental.

Jane, we don't believe that people with intractable psychiatric problems should kill themselves, much less have an institution promoting euthanasia for the mentally ill (what's next?).  We believe they should change doctors, try different or unconventional therapies, seek other opinions from experts,  and we see psychiatric conditions as treatable.

Re: The suicide prevention conference: they invited us to present, we had never heard about the conference before.

I am sorry to be so defensive.  The comments from this post left me very angry. 

I will leave you with a quote from the comment section of the NYTimes article on their Special Teams:

  Casey from Denver wrote:
This work is profoundly important because many people thinking of suicide change their mind. A study by Dr. Richard Seiden of people prevented from jumping from the Golden Gate Bridge found that after an average of 26 years, 94% were still alive or died of natural causes. One of the rare jumpers who survived said later:
“The last thing I saw leave the bridge was my hands. It was at that time that I realized what a stupid thing I was doing . . . It was incredible how quickly I had decided that I wanted to live.” So keep up the good work, you brave men and women of the Emergency Service Unit!

Reading While Depressed

I have to get off that suicide topic. Here's something a little more helpful:

In the current issue of the Paris Review, a reader writes in asking what she should read while depressed. Review writer Sadie Stein answers with a number of interesting suggestions, followed by 67 reader comments with additional ideas.

If you need to clean your head out from our last post and discussion, read this:

Life-Affirming Reads

Murder of the Self

Darn you, Blogger. I'm trying to get two presentations done along with lots of other work and there you go, distracting me.

So we have the issue of suicide and criminal law and a discussion of whether it's a crime to kill yourself. Dinah and I just did a presentation about social media and suicide at a local conference on suicide, so the topic is fresh in my mind.

To my knowledge there are no states that still have laws against someone who attempts suicide. In some states, suicide is a common-law crime that could bar recovery in civil cases (and insurance companies don't pay out for the survivors of people who kill themselves).

The complications come up when the suicide attempt puts others at risk. When someone shoots himself and lives, but puts others in danger during the act he could be charged with reckless endangerment or criminal negligence (as well as the associated handgun offenses if applicable). Yes, people have gone to prison for this. Possession of a controlled substance without a prescription, even if possessed for the purpose of suicide, is a crime.

A lay person who forms a suicide pact with someone could be guilty of conspiracy to commit murder (at worst) or aiding and abetting a suicide. Euthanasia, the killing of a terminally ill person, is less of an issue now that we have living wills and advance directives. There is no constitutional right to assisted suicide, by a physician or anyone else, according to two cases decided in the 1990's by the U.S. Supreme Court. Few states allowed physician-assisted suicide, and many have recently passed laws banning it.

Suicide is similar to drug addiction in that both could be considered "status offenses"---it's not a crime to be who you are (someone with suicidal ideation or someone with an addition to drugs), but it could be a crime to possess the materials to express who you are (drugs, a gun, etc) or to carry out some aspects of the behavior (buying the drugs, firing the weapon, etc).

No time to put up specifics about which states and how many of them do what, just an outline of the issues FWIW.