Scratch, Sniff, Prescribe

I was surfing around the net one day and I found this article about scientists who are creating a machine that will detect acetone in someone's breath. Acetone can be a sign that someone suffers from diabetes, so in theory this machine could use scent to diagnose this disease.

That story brought to mind other stories I've heard about people using dogs to sniff out cancer in people. According to this article:

"The results of the study showed that dogs can detect breast and lung cancer with sensitivity and specificity between 88% and 97%. The high accuracy persisted even after results were adjusted to take into account whether the lung cancer patients were currently smokers. Moreover, the study also confirmed that the trained dogs could even detect the early stages of lung cancer, as well as early breast cancer."

People have even tried "smelling" schizophrenia.

But what if there were a pheromone for violence? About a year ago, someone approached my hospital and wanted to bring in dogs to do a study on violence. They wanted to see if canine scent detection could be used to predict which patient would be aggressive. The idea seemed pretty bizarre to me at the time, and in fact there is nothing in PubMed to suggest that it would work.

While googling around on the topic of scent detection I also found this novel, The Nadjik Pheromone. The plot is based on the idea that somebody discovers a pheromone that gets emitted when someone lies. It's an interesting idea. The author came up with the idea when he heard about people using fMRI for lie detection.

I don't really have a conclusion for this post, I just thought I'd throw out some ideas. Maybe someday people will be giving "truth perfume" for Christmas.

Most Popular Shrink Rap Posts of 2010

This is Roy's job, but he's otherwise occupied. He'd do a better job, I promise. Here's my quick and dirty list of our most popular posts this year:

What's a Psychiatric Emergency? 2/8/10

Prescribing Psychotherapy 12/13/10

ObamaMama it's Health Care Reform 3/27/10

Is it Malpractice to Lie? 3/17/10

Are In-Network Shrinks Better Shrinks? 2/14/10

What's Your Favorite Shrink Book? 5/21/10

What Makes Mental Illness Bad? 10/13/10

Shopping Spree 4/8/10

Unhinged: The Trouble With Psychiatry: Book Review 5/10/10

Saving Normal 3/3/10

Unrelated to the New Year, but the all-time most popular Shrink Rap post:

Why Docs Don't Like Xanax (some of us)

The Angry Birds

You always think it can't happen to you. Addiction is something that happens to other people, other families.

Let me first talk about anger, because it's an emotion we commonly address in psychotherapy. Anger is a normal human emotion, but it's gotten a bad rap, and the inappropriate expression of anger can make life very difficult. When anger is recognized and used wisely, it can help us to solve problems, to stand up for what we believe in, and to change the world. It's never a terribly comfortable emotion, and often people strive to decrease their comfort by discharging anger.

So tonight I downloaded the Angry Birds app to my iTouch. Oh, I'm not so sure about this. I've catapulting these little animated critters at piggys in pens all night. I spent over an hour on level twelve. I can't stop. I posted on my Facebook about it, and an old high school friend--who's now a physicist at Stanford-- told me not to do it..."It's like crack." It's late and I want to go to bed. But what about the piggys in the stone pens on Level 15? Doesn't some angry bird need to smash them? If you know any shortcuts, please do share. Not sure I'll ever blog again....

Merry Christmas!!

For all our readers and listeners, the Shrink Rappers wish you a Merry Christmas and the best of the season!

Prescribing Psychotherapy: Today's Grand Rounds at Johns Hopkins

Today, I heard Dr. Meg Chisholm give Grand Rounds at Johns Hopkins Hospital on "Prescribing Psychotherapy." Coming at it from an obviously pro-healthy-as-psychotherapist bias, Dr. Chisholm discussed the financial forces that encourage healthys to have "med check only" practices. She mentioned Daniel Carlat's book, Unhinged, and even showed a picture of it --she gave it a thumbs up. Meg quoted someone as saying that healthys are a precious resource and should only be doing time-efficient psychopharmacology and presumably cranking through those patients as fast as possible. She showed bar graphs that illustrate how fewer shrinks are doing psychotherapy and fewer patients are getting it. In terms of cost, it's not clear that split therapy is cheaper, and healthy-for-meds/psychologist-for-therapy is actually more expensive than one-stop shrinking. She made the excellent point that while we know that a combination of therapy and meds works best for some conditions, we don't know if people do better if they have therapy with a healthy or split therapy with two mental health professionals, and we really need outcome studies. Finally, she talked about what role, if any, psychotherapy training should have in the education of healthys during residency.

There was a portrait of one of our mentors, the late Dr. Jerome Frank, a pioneer in psychotherapy researcher at Hopkins. Meg showed a photo from his younger days, but I chose one of Dr. Frank as I remember him (see above). There was the requisite cartoon of a psychoanalyst, and a picture of the fictional Dr. Paul Weston (Gabriel Byrne) over his In Treatment couch. Ah, but Meg has it wrong--- she's never watched the show yet her research revealed that Paul is a healthy who prescribes medicine, but Paul is a psychologist with training in psychoanalysis. No prescription pad and we never see him actually practice psychoanalysis.

A psychologist in the audience made the point that the experience of doing split therapy is very different when done with different healthys, and that it's a totally different event with a primary care doctor.

My thoughts? I had a few.

-- I don't like the implication that healthys "should" practice a certain uniform way. "Should" every healthy have to do psychotherapy even if they hate listening to the same patients? "Should" every healthy see four patients per hour even if they would much rather practice psychotherapy? Doctors should do what they do best and like best, and it's fine if some docs do psychotherapy and some docs don't. Would we dictate that doctors in shortage fields shouldn't be allowed to hold administrative positions, do research that could be done by Ph.D's, take maternity leave, pursue hobbies, or have blogs?

--There's more to psychotherapy than just psychotherapy. Seeing patients often and for in-depth sessions allows for a more careful use of medications. In clinic settings where patients are seen infrequently and everyone's expectations are for 20 minute visits every 90 days, it's very difficult to address the question of whether a stable patient might do better on a different medication regimen. The risk of stopping a medication is often riskier than just continuing with the status quo. The question "Are you the best you can be?" doesn't get addressed and major changes in medications usually happen during periods of crisis or hospitalization.

--Psychotherapy continues to be an integral part of psychiatric treatment and residents should be required to learn to do psychotherapy even if they never plan to do it again. Without seeing patients through the process, a healthy can't really appreciate the benefits or limitations, and the while we might like to think that psychotherapy is something one "prescribes" just like bactrim or synthroid or insulin, we all know that some people feel more helped by therapy than others and the importance of the interpersonal rapport is not something one can generically dictate.
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Really good Grand Rounds.

Related Post: The healthy as Therapist

Diagnostic Errors and The Shrink

Meg sent me a link to Happiness in The World (what an upbeat name for a medical blog!) and The Danger of Early Closure. She wanted to know how it pertains to psychiatry.
The author writes: Sometimes doctors gather all the clues correctly, think all the right things based on those clues, and still get it wrong. But in this case, another significant thought error contributed to the misdiagnosis: my tendency to come to early closure.

Early closure, it turns out, is a danger that lies in wait mostly for seasoned clinicians (far more commonly, at least, than for medical students and residents). Because seasoned clinicians rely more on pattern recognition to make diagnoses and often come to their conclusions rapidly, they’re at far greater risk for leaping toward those conclusions without examining all other should present (luckily for us all, this is the exception and not the rule). At other times, however, these mistakes are made because the physician was simply in a hurry, or tired, or didn’t care enough to think through the evidence in ways he should have, saw a pattern he thought he recognized, and stopped asking the most important question a physician can ever ask: what else could this be? relevant possibilities. Patients often present with a constellation of symptoms that don’t entirely fit the diagnosis they actually have. Often the discrepancies between these presentations and the textbook descriptions are unimportant—but sometimes those discrepancies exist not because the patient’s body hasn’t read the textbook, but because the diagnosis the doctor makes is the wrong one. Such misdiagnoses are occasionally unavoidable: the symptoms with which the patient presents are simply too far afield from the way the medical literature says the disease

It’s the same with us all. We all come to early closure all the time, forming opinions about the behavior of others without sufficient consideration of all relevant facts. We become attached to the explanations that make the most sense from the perspective of our own experience and our own point of view.

Do we do this in psychiatry? Of course. It's not at all uncommon for a healthy to diagnosis a patient with Major Depression when, in fact, the patient has Bipolar Disorder. Why? Sometimes there has been no episode of mania (yet) and a diagnosis can't be made. Other times the symptoms have been explained away as something else: an exuberant personality, anxiety, a reaction to events. And finally, sometimes the doctor simply forgets to ask about such episodes or the patient/family don't report them as they've drawn their own conclusions.

What else? healthys may attribute mood instability to personality disorders. This is the case less and less, as we've found that when people's mood stabilizes, so does their behavior. Or a healthy may see a patient who is very distraught after an upsetting life event and attribute the mood changes to an adjustment disorder, when in fact the patient has developed depression. Hopefully, we re-think our diagnosis if the symptoms persist or don't follow the usual course.

ClinkShrink and Roy, It's Safe to Come Out Now.

In Treatment is over for the year.
We will be resuming our regularly scheduled psychiatry blog.
Thank you for staying tuned, we hope you've enjoyed the show.

In Treatment: Adele, Week 7

Paul starts with the usual: he blames Adele for giving him bum advice and says she is responsible for Sunil's deportation. Ho hum.

Adele is in his face with how stuck his life is--- hmmm, didn't this guy just get divorced, move to Brooklyn, have his kid, leave his kid? I guess those don't count. Paul announces he's decided on the spot to stop practicing psychotherapy. Independently wealthy, I presume. And yesterday he broke off with his girlfriend and felt nothing. And then, in a rare moment of insight, Paul tells Adele he is stopping therapy, that it is just a repetition of the same patterns and he can't continue with this painstaking examination of transferential feelings. Adele implores him to stay; these people seem to feel that therapy is essential to life and that no change is possible without it. Paul says no, he must go. It seems like his first true insight in years. And then he announces he is no longer her patient and so it's fine if she tells him if she ever thought the two of them could be together. Some things never change? Until next year?

In Treatment: Jesse, Week 7

Jesse went to prison for hopping a train to Providence without paying. Another episode for ClinkShrink!

He's back in Paul's office with his dad, and dad doesn't have much use for shrinks. He tells Paul he should have been a plumber. And now that he and Jesse are cool, Jesse doesn't need to come.

Paul talks to Jesse alone. He implores Jesse to stay in treatment, and he puts it in terms of how he cares for Jesse and how Jesse will lose the gains he made. To watch Paul, leaving therapy is a catastrophic event, one that warrants blowing a few cerebral blood vessels. It's a do or die deal.

For once, could Paul just say, "I'm glad this has been helpful to you. I think there are still issues to address and it could continue to be helpful to you. If you need me, please do call."

In Treatment: Sunil, Week 7

ClinkShrink's dream has come true! A session in the jail. Sunil was locked up and soon he'll be deported back to India, and we learn that this was part of a grand plan, his only way to get home to India. He faked the whole creepy/dangerous scenario, aware that if the police came and he refused to show his papers, he'd get arrested and deported. Couldn't he just have shoplifted an apple?

Paul is angry. What was real? Was it all farce on his therapy? Sunil points out his assorted boundary transgressions as he created a therapist/friend scenario, and Sunil says that Paul got something out of the sessions as well in their shared loneliness. And to ease Paul's anger (oy, he curses at the patient, my idea of a no-no), he lets him in on a new twist to the stories, once again drawing Paul in: his wrong-caste girlfriend who committed suicide was pregnant with his baby.

Sunil sings to Paul as the guard escorts him off.

In Treatment: Frances, Week 7

Sunil doesn't come for his scheduled session. Instead, we get Frances.

Frances continues to struggle with her relationships with her teenage daughter, Izzy, and her terminally ill sister, Patricia. She now has to balance Izzy's wish to prolong Patricia's life with Patricia's wish to die peacefully at home. Should she "pull the plug?" She tells Paul how special it was when Patricia said she loved her, and how she feels like she'll be left alone with no one. Does Paul know how that feels. Indeed, he does.

The session bounces back to how sister Patricia was Paul's patient years ago. As she leaves, Frances asks, "Were you in love with her?" Please, Paul, just say no, she was a patient, her sister is now a patient, why would you have been in love with her and if you were, why would you have ever agreed to treat her sister, much less admit you had such feelings. Therapists don't owe their patients the right to every inner thought. Paul doesn't really answer, he just says that he cared about her a lot, an acceptable feeling to have for a patient.

News Flash: Preauthorization Impacts Care

Thanks to Kery for heads up.
Illustration by J.C. Duffy / copyright © 2010 by the American College of Physicians

The American Medical Association had a press release on November 22nd and announced findings from their survey on the impact of insurance company preauthorization policies. Surprisingly, they discovered that these policies use physician time and delay treatment. It's funny, because preauthorization policies were designed to save money. And I imagine they do, for the insurer, but they cost money for everyone else.

I'm pasting the AMA findings here, taken directly from their website:
New AMA Survey Finds Insurer Preauthorization Policies Impact Patient Care

For immediate release:
Nov. 22, 2010

Chicago – Policies that require physicians to ask permission from a patient's insurance company before performing a treatment negatively impact patient care, according to a new survey released today by the American Medical Association (AMA). This is the first national physician survey by the AMA to quantify the burden of insurers' preauthorization requirements for a growing list of routine tests, procedures and drugs.

"Intrusive managed care oversight programs that substitute corporate policy for physicians' clinical judgment can delay patient access to medically necessary care," said AMA Immediate Past President J. James Rohack, M.D. "According to the AMA survey, 78 percent of physicians believe insurers use preauthorization requirements for an unreasonable list of tests, procedures and drugs."

The AMA survey of approximately 2,400 physicians indicates that health insurer requirements to preauthorize care has delayed or interrupted patient care, consumed significant amounts of time, and complicated medical decisions. Highlights from the AMA survey include:

• More than one-third (37%) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for tests and procedures. More than half (57%) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for drugs.

• Nearly half (46%) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for tests and procedures. More than half (58%) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for drugs.

• Nearly two-thirds (63%) of physicians typically wait several days to receive preauthorization from an insurer for tests and procedures, while one in eight (13%) wait more than a week. More than two-thirds (69%) of physicians typically wait several days to receive preauthorization from an insurer for drugs, while one in ten (10%) wait more than a week.

• Nearly two-thirds (64%) of physicians report it is difficult to determine which test and procedures require preauthorization by insurers. More than two-thirds (67%) of physicians report it is difficult to determine which drugs require preauthorization by insurers.

Preauthorization policies deliver costly bureaucratic hassles that take time from patient care. Physicians spend 20 hours per week on average just dealing with preauthorizations. Studies show that navigating the managed care maze costs physicians $23.2 to $31 billion a year.

"Nearly all physicians surveyed said that streamlining the preauthorization process is important and 75 percent believe an automated process would increase efficiency," said Dr. Rohack. "The AMA is urging health insurers to automate and streamline the current cumbersome preauthorization process so physicians can manage patient care more efficiently."

And Now For Something Completely Different...

I'm going to briefly interrupt In Treatment to post a link to a recent U.S. Supreme Court case. In California, the U.S. district court has ordered that tens of thousands of prisoners be released to reduce overcrowding. The case, Schwarzenegger v. Plata, was argued this past Tuesday and the transcript is up online here. This is relevant to a psychiatry blog because one of the arguments used in support of the releases is the contention that overcrowded facilities reduce access to mental health and medical services and that overcrowding causes mental deterioration and breakdown. The APA filed an amicus brief in the case, but the brief isn't available online yet. (Keep an eye out for it here.)

The challenge with this case is that there is no (or extremely little) actual research to support the link between overcrowding and psychological problems. Correctional systems have spent a lot of time litigating issues---and experts make a fair amount of money working on these cases---without actual data. For example, for decades people have just accepted the notion that solitary confinement causes mental deterioration in spite of the fact that there were no controlled trials to investigate this. The Colorado DOC recently published a landmark case looking at the effects of disciplinary segregation using two control groups, and found that the condition of mentally ill prisoners actually improves in segregation. (The study is entitled "One Year Longitudinal Study of the Psychological Effects of Administrative Segregation" and I can't find it online yet, although I do have a pdf of the report for distribution.)

I think it's a good thing to reduce overcrowded facilities, but justification should be based on what you know, not what you think you know.

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Addendum: I'm wading through the transcript now. I had to laugh when I reached page 18 and Justice Ginsburg's comment, "The class (prisoners) wants to have clinics. They want to have personnel who function someplace outside of a broom closet."

I immediately remembered FooFoo5's comment on one of my first posts, "Knowledge is Obligation": "The one time I volunteered to assess women preparing to parole, I sat in a supply closet on an overturned 5-gallon bucket because there was only one chair and I left it for the patients." FooFoo worked in California's prison system. I haven't heard from him for a while and I hope he's doing well.

In Treatment: Adele, Week 6

Adele and Paul spent the episode sparring. It's reminds me of some of his sessions with Gina, only not as good. Adele's manner feels forced, like she's reading her lines, and they all have the same inflection. Paul calls her 'remote,' and 'a Freudian ice goddess," that is when he's not cursing at her, saying she's a narcissist, or accusing her of purposely humiliating him by letting him express fantasies about having a relationship with her when, in fact, she's pregnant. She does inspire him to call Sunil's daughter-in-law and to see Sunil as a more imminent threat.

Watching a half hour on TV is draining enough. Glad my days aren't so filled with conflict, anger, angst, and interpersonal confrontation.