This Month in Archives of General Psychiatry
Archives of General Psychiatry
In a genome-wide survey of large, rare structural genomic variants (copy number variants [CNVs]), Grozeva et al (SEE ARTICLE) found that schizophrenia and ...

New York Times (blog)
Finding Activities for Parents With Memory Loss
New York Times (blog)
I've invited the clinical psychologist Cynthia Green, an assistant clinical professor of psychiatry at Mount Sinai Medical Center in New ...

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For Hoarders, The Mess Begins In The Mind
NPR
At the University of California, San Diego Department of Psychiatry, psychologist Catherine Ayers specializes in anxiety disorders and late-life hoarding. ...

and more »

We've talked before about whether having the diagnosis of a mental illness should prevent a person from pursuing certain careers. We've also mentioned that pilots, in particular, can not be on psychotropic medications. One concern is that a depressed pilot might not seek treatment because s/he fears losing her job. Is it better to have a pilot with untreated mental illness, or one on medication?

In The Wall Street Journal, Shirley S. Wang and Melanie Trottman write that the FAA has reconsidered this policy and will allow pilots to fly if they are being treated with Zoloft, Celexa, Lexapro, or Prozac. They write:

The new policy doesn't mean pilots who want to begin taking one of the medications can get in the cockpit right away. Before being granted a waiver by a physician certified by the FAA, a pilot must be considered "satisfactorily treated" for 12 months; in the meantime, he or she will be grounded.

For pilots who have been secretly taking antidepressants, the FAA is offering a grace period. The agency said it wouldn't take action against such pilots if they come forward within six months. However, pilots with a recent case of depression or who want to begin a new medication regimen will be subject to the one-year waiting period, according to FAA spokeswoman Alison Duquette. "We're really looking for stability," she said.

Grounded for 12 months? Seems like a long time. What do grounded pilots do? Do they get paid? Is this really destigmatization?

----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

Reuters
Depressed Pilots Can Fly on Medication, FAA Decides
Wall Street Journal
Psychiatrists said it usually takes three to six weeks for an antidepressant to begin taking effect, and doctors should have a good sense of how people are ...
FAA Ends Ban on Depressed Pilots in CockpitsABC News
FAA Eases Rule on Antidepressant UseMedPage Today

all 617 news articles »

Fibromyalgia Symptoms Eased by "Lifestyle Physical Activity"
Medscape
... Behavior, and Society at Johns Hopkins University School of Medicine in Baltimore, Maryland, noted in an email to Medscape Psychiatry. ...

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STATE v. McGOVERN
Leagle.com
{¶ 16} Theodor Rais, MD, child and adolescent psychiatrist and acting director of the Kobacher Center at the University of Toledo, testified that he was the ...

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To scientists, laughter is no joke _ it's serious
The Associated Press
Dr. Margaret Stuber, a psychiatry professor at University of California Los Angeles Medical School, studied whether laughter helped patients. ...

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In case you haven't heard, we've got ourselves health care reform.
What do you think?
Will this be a good thing for psychiatric patients?
Will this be a good thing for psychiatric docs (the shrinks among us?)

Personally, it's been so much commotion and so many pages, it's been way too much to follow (and no one asked my opinion anyway). I think I'm happy for movement, we've been stuck for so long with a system that just doesn't make sense. I'm told most people are happy with their health insurance. Are you?

Go for it, write in our comment section!----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

The title of this post comes from one of the questions in the Minnesota Multiphasic Personality Inventory, which I had to take when I applied to medical school. And I do like flowers. One of the things I like about the place where I work now is the fact that it's filled with plants---I don't know enough about horticulture to say what they are---but I think they are mother-in-law's tongue, ferns, philodendrons and other bushy green things. In front of the hospital there's a bed of tiger lillies and I can't wait for them to start blooming now that it's Spring.

Our hospital has a horticulture program. Patients who have worked their way up through the privilege level system and are safe enough to leave the ward are allowed to tend the many green plants lining the hallways and windows of the hospital. They do a terrific job and the place is beautiful and warm. I appreciate this a lot because I have a black thumb. When I walk into a nursery the plants scream and run for cover.

I think the patients appreciate the program because being able to participate is a sign of progress. Being able to gain some freedom and be responsible for another living thing gives a sense of independence and responsibility. It's also quite relaxing and peaceful to be surrounded by beauty.

Psychiatric hospitals and prisons have frequently used agriculture or horticulture for therapy and rehabilitation. I know of a maximum security prison where inmates with the highest privilege level are allowed to participate in a bonsai program, growing miniature trees.

Nineteenth century psychiatric hospitals relied upon hospital farms to provide for the needs of the patients. They grew their own food and milked their own dairy cows, which for some patients I'm sure was a source of self-sufficiency and pride. One former hospital farm, the Brattleboro Retreat Farm, still exists and is open to the public. In 2008 the New York Times published Tara Parker-Pope's article Better Mental Health, Down On The Farm in which commenters talked about their own experiences caring for animals during episodes of mental illness. One commenter talked about his horses as "a reason to go on" while depressed, because he had to feed and groom them even in bad weather.

While I didn't grow up on a farm, I did live in a rural community and many of my friends were farm kids. I still get teased for commenting on the progress of the corn crops as I drive through the country. I know farm life is not for everyone. The NYT article mentioned a Norwegian study that compared psychiatric patients treated with standard pharmacotherapy versus a group given standard therapy along with a "farm intervention", where they were asked to work with cows, sheep and horses for three hours a week over a 12-week period. By the end of that time the patients with farm experience had significantly higher self-efficacy and coping skills. Coincidentally, the farm group also had a higher dropout rate. The article didn't mention why the patients dropped out, but I can imagine why----cow pies are definitely not therapeutic.----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

While I was away, ClinkShrink did a Spectacular job of keeping up the blog. And the rare moments I could get computer access, for 20 shekels a shot, I got to play beat-the-clock attempting to get through my email. There were about a zillion in response to Clink's posts. Great posts (and beware the surgeon who dares to lie to Dinah)...but no pics? Why no pics, dear ClinkShrink? Ah, but it's not too late--- I will help her out here.
Dinah's back.....
----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

Psychiatrists' Relationships With Pharmaceutical Companies Part of the Problem ...
Journal of American Medical Association (subscription)
Author Affiliation: National Institute of Mental Health, Bethesda, Maryland. 1. Freedman R, Lewis DA, Michels R; et al. Conflict of interest—an issue for ...

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In this show we continue with our guest Dr. Pat Barta of the Adventures in Telepsychiatry blog.
We talk about electronic health information systems and Clink continues her rant which she started in her post Rage Against The Machine. Roy mentions the Certification Commission for Health Information Technology and the American Recovery and Reinvestment Act which provides funding incentives for doctors who use health information technology. We cover developing standards for behavioral health information technology, including personal health records which allow patients to store their own information voluntarily "in the cloud", on a server. Dr. Pat Barta talks Open source health record systems and information security.
Health Data Rights is an organization that developed a proposed declaration of rights for patient data. Another organization addressing this is SpeakerFlower, of which Roy is the spokesperson.
Dinah talks about her blog postWhat's An Emergency? and wonders how flexible psychiatrists should be when a patient says they need to be seen right away. Which situations are truly emergencies? What should you do if a patient turns down multiple appointments offered for that same day? Should your office voicemail tell people to call 911?
Finally, Dinah wonders what has happened in states with medical marijuana laws. She mentions KevinMD's blog post Medical Marijuana Has Doctors Asking Questions. Should marijuana be prescribed for attention deficit disorder? How do you do clinical research on a controlled substance? ********************************
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Send your questions and comments to: mythreeshrinksATgmailDOTcom----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

Don't ask me how I stumbled across this story, but I thought it was fun enough to put up on the blog. It's a study done by a parrot rescue organization in Minnesota that describes a kind of trauma recovery program for birds, using human development models. See the full article: "Avian Affective Dysregulation: Psychiatric Models and Treatment for Parrots in Captivity".
The group has a clinical psychologist and trained volunteer caregiver "therapists" while the parrots are known as "clients" (not "patients"). The five cockatoos described in this study are even given pseudonyms to protect their anonymity. The team develops individualized treatment plans for each bird that are supposed to help them recover from traumatic rearing through gradual exposure and de-sensitization.
In this paper the researchers classify the birds according to one of four attachment styles: secure, insecure-avoidant, insecure-ambivalent and disorganized-disoriented. Each attachment style is thought to be the result of certain early and juvenile caregiver experiences. Birds exposed to frequent changes of caregivers, or caregivers who were abusive or unpredictable, developed insecure or unstable attachments to other birds and to human caregivers. These birds had a number of bird "symptoms" or behavior problems such as withdrawal, lack of affect (unh...how can they tell if a bird has a flat affect?), attacking or biting behavior or a "flat crest" (I think that's the bird equivalent of a dog with it's tail between it's legs).
The paper really doesn't go into detail about how the birds were treated except to say they were given opportunities to "exercise autonomy, agency, and social and physical competence". They were also gradually reintroduced (or introduced for the first time) to other birds. The cockatoo which came from a stable, secure and consistent human family was surprised by the other birds (since he had never been around them before), but he adapted quickly to the flock and didn't show any maladaptive behaviors. The bird from the violent and substance abusing family had unpredictable and sometimes violent reactions to other birds. One bird was given a "social facilitator"---another bird who supposedly modeled appropriate bird behavior and taught him how to adapt to the flock---his own emotional support animal.
They also tried giving the most unstable cockatoos psychiatric medication such amitriptyline, clomipramine and Prozac, but the results were inconsistent. (And yes, they even figured out a way to give informed consent.)
I thought people might enjoy reading about "transpecies psychiatry". You might find it interesting to read about elephant PTSD as well as EMDR therapy for traumatized horses. ----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

John Oldham Chosen APA's Next President-Elect
Psychiatric News
Oldham's opponent in this year's president-elect race was Massachusetts psychiatrist Donna Norris, MD, with Oldham winning 54 percent of the vote to 46 ...

In the New York Times this week we have a story entitled Animal Abuse as Clue to Additional Cruelties. In this article Ian Urbina discusses the problem of people who hoard animals and the connection between animal abuse and violence toward people.

The link between animal cruelty and antisocial behavior is well known and was first studied in the 1960's by a researcher at Washington University by the name of Lee Robins. Dr. Robins followed the outcomes of children referred to a local mental health center for conduct problems, and learned that about one third of them developed antisocial behavior as adults. This is where we get the current conduct disorder criteria for antisocial personality disorder found in DSM-IV: firesetting, theft, running away, truancy and animal cruelty.

States are passing laws to better identify and track people who hoard or abuse animals, with the idea that people who do this are also likely to be abusing or neglect humans in their households. The laws allow for sharing of information between people who investigate domestic violence or child abuse and people who investigate animal neglect cases. Some states are even passing laws to create registries of animal abusers.

Two parts of this story caught my attention: the registry issue and the idea that neglecting an animal becomes a predicate offense for other investigations. Here in Maryland we're big on registries. We have a sex offender registry and child abuse and neglect registry. We have a law requiring child welfare agencies to compare recent birth certificate information to the child abuse registry, to see if any known child abusers are having more kids. Now maybe we should also check to see if they're adopting pets.

The whole idea of registering and tracking people is a bit uncomfortable for me. Registries don't prevent crime but they can prevent people from getting jobs, buying homes and reintegrating into society after they've served their time. Being on a registry (or not being on one) is not truly reflective of the risk that person poses to society. A demented little old lady found with 200 cats in her basement could end up on the Internet, with the implication that she since she has neglected animals she also abuses children. Registries also don't seem to do much for preventing people from getting access to what makes people truly violent: guns and alcohol. Perhaps we should require liquor stores to check registries before any beer transaction. While we're at it, violence is associated with mental illness, untreated mood disorders and personality disorders. Maybe a registry of psychiatric patients?

Please. Enough. I doubt Dr. Robins ever expected this kind of outcome to her work. The purpose of studies like hers was to identify people at risk, for intervention and treatment, not for prosecution and public censure. I think we need to get back to that original idea.----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

KOMU-TV
'Match Day' ends suspense for medical students
Baltimore Sun
"Oh my God, I'm shaking," said Marie-Rose Alam, 26, as she posed for a photo with her match letter in hand, noting a residency in psychiatry at Georgetown ...
Match Day Brings Joy (and Relief) to the School of Medicine Class of 2010UMB News

all 107 news articles »

I saw this film over the weekend after a recommendation from a friend. It's a Korean film about ostracized misfits who find one another in the midst of a harsh society. The main character, Jong-du Hong, is released from prison after serving time for killing someone in a drunk driving accident. His family are not happy to see him again. They are hard-pressed for money and have had to squeeze into a small apartment with his many siblings. His family does not hesitate to tell him that he is a burden and that they were better off when he was locked up.

He visits the family of the person he killed to make amends, only to find them in the process of moving out of their apartment. They are leaving behind the child of the accident victim, Gong-ju Han, a severely disabled woman with cerebral palsy. Jong-du confronts her brother as they are leaving and demands to know who will take care of her. He is kicked out of the apartment and she is left alone, with physical contortions that horribly distort her limbs. It was painful to watch.

Jong-du returns repeatedly to try to visit Gong-ju, to bring her flowers and to check on her. Finally, one day he is let into the apartment. He tries to rape her then flees when she passes out.

This is the point where the movie becomes inexplicable to me. Following the attempted rape Gong-ju fantasizes about Jong-du and imagines having a lover, and struggles against her cerebral palsy to put on makeup. Jong-du returns and the two become lovers. Their train-wrecked lives come together in a predictable way. One physically damaged, one psychologically damaged, both without psychological or social support. The result is inevitable and predictable.

The Rotten Tomatoes web site gave this film an 89% favorable rating, although I'm not sure why. One of the difficulties of this movie, besides the implication that rape can trigger love, is the fact that Jong-du's facial contortions made it impossible to read her emotions, and I was left wondering if she was in pain, afraid or ecstatic. When it was crucial to directly tell the audience what she was feeling the director cut to a fantasy mode, and the physically-whole actress acted out Gong-ju's feelings. We learn she is entranced by this man, that she fancies herself teasing him and playfully flirting with him, that her days are filled with wonder and fulfillment when he is around.

The most potent part of the film was the portrayal of how this disabled woman was treated by Korean society----she was refused service at a restaurant and rejected at a family gathering---overt discrimination highlighted by Jong-du's naivety. He brings her to his mother's birthday party only to be confronted by his siblings about his inappropriateness. Gong-ju's family can't even imagine that anyone could love her, and they take it for granted that he is abusing her when they finally do make love.

Jong-du ultimately goest to prison after a false rape allegation, but personally I think he should have been there quicker after the first, real, attempt.
----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

I came across this interesting malpractice case via the HealthLaw Twitter feed which I've been following for a while now. The case is Willis v Bender, a 10th Circuit Court of Appeals case out of Wisconsin.
In this case a surgeon was sued by his patient following complications from a laparoscopic cholecystectomy (gall bladder removal). Before the procedure he explained the risks of the surgery to her, and she also asked him questions about his experience and success rate with the procedure. She asked additional questions about whether he had ever been sued for malpractice or had any action taken against his medical license. He answered no to both questions and added that he had an almost perfect success rate with the surgery. Well, bad things happened. The patient suffered a perforated intestine and an infection. She later found out that the doctor had lost a patient during this same procedure, and that he was disciplined for the board as a result of that case.
At trial the jury found in favor of the doctor because even the plaintiff's expert couldn't say that the complications were the direct result of improperly performed surgery. Even properly done surgery of this type carried the risk of perforation, bleeding and infection. The plaintiff also alleged that the doctor failed to give her informed consent because he gave false information about his personal background. The trial court wouldn't allow the informed consent issue to be raised because in Wisconsin the law only required that physicians tell patients the material risks of proposed treatment. There was no affirmative duty to disclose professional background information even when asked.
So the plaintiff appealed.
The 10th US Court of Appeals reviewed various similar informed consent cases and found that courts took different views on whether or not lying to a patient about a physician's background could be considered a breach of informed consent. Some courts held that doctors could be found liable only if they lied regarding the risks of the proposed treatment. In this case, the appellate court decided that the patient should have had a chance to make the argument, and sent the case back for retrial on that issue.
We'll see what ends up happening on retrial, but I thought this was an interesting emerging area of law. What if the issue wasn't technical incompetence? How much "personal background" should a doctor have to tell a patient before treatment can begin? Medical school grades? Failure to pay income tax? Should doctors be required to disclose to patients the fact that they've been treated for mental illness themselves? ----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.

I found an interesting article on the Public Library of Science web site called The Cultural Dynamics of Copycat Suicide. (And thanks to the author for being willing to share his information under a Creative Commons license---this is how medical research should be!)

The author, Alex Mesoudi, used a computer model to study the effects of social learning and mass media influence on suicide clusters. He used a statistical method to see if suicides were clustered in time and space at an unexpectedly high frequency. This method is called an agent-based similiation, and is commonly used to model transmission of infectious disease. I'm not going to pretend to understand the statistics behind this! If you're curious you can read that part of the article.

He started by explaining the difference between point suicide clusters and mass clusters. Point clusters are suicides that are grouped together in time and space, while mass clusters are suicides that are grouped together in time, but are separated geographically. Suicide clusters have been thought to be due to social learning or mimicry, but it's also possible that they occur through homophiliy (the tendency for similar people to pool together in groups). Mass suicides are thought to be due to the influence of prestigious individuals (eg. celebrity suicide deaths) combined with coverage by the media. This leads to a one-to-many transmission model.

The computer model was run using three different assumptions: that suicides were totally random and unclustered, that clusters were due to social learning, and that clusters were due to homophily. He used different formulas to generate "suicides" under each model, and looked at the kind of clusters (spatiotemporal versus just temporal) that resulted.

What he found was that social learning caused spatiotemporal point clusters while homophilic clusters were more likely to be spacial rather than temporal. In order to understand this better, imagine the difference between teenage suicide epidemics versus correctional suicides. Teen suicides clusters happen among individuals who know each other, they happen in the same geographic area and within a short time frame of one another. These are the "social learning" clusters. Correctional suicides happen at a rate higher than in free society (in other words, they're geographically 'clustered' in a jail or prison), but are spread out over time. These are the homophilic suicides, in other words deaths by high risk people who happen to be grouped together. Based on this study, the correctional deaths are less likely to be due to social learning or mimicry.

Finally, the author studied the factors influencing mass suicide clusters: deaths that happen at the same time over a broad geographic area. These the kinds of suicides you see when a celebrity commits suicide. They are generally associated with a lot of media coverage. The computer model found that social learning played almost no role in these deaths.

It's a really complicated paper and I'm sure I didn't do it justice, but I thought it was pretty fascinating that someone could basically recreate the kind of suicide death patterns we see in the real world based on a theoretical mathematical framework. And I liked the term this author used for this kind of experiment: in silica. If in vivo experiments are done on animals or humans and in vitro experiments are done in test tubes or petri dishes, then "in silica" is a great term for computer model experiments.

And if none of this post made sense, hang on and I'll resurrect it in one of our podcasts.----- Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.