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American Psychiatric Society's kudos for Dr. Ricardo Espaillat - Dominican Today

American Psychiatric Association - 16. January 2014 - 15:52

American Psychiatric Society's kudos for Dr. Ricardo Espaillat
Dominican Today
SD. The neuro-psychiatrist Ricardo Espaillat was bestowed the "Distinguished Fellow," the highest honor with which the American Psychiatric Society awards to one of its members. The honor, a national recognition in the United States, is awarded to ...

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Why Psychiatrists Don't Participate with Insurance Networks

Shrink Rap - 13. January 2014 - 8:57
In 2007, I wrote a post called Why Shrinks Don't Take Insurance.  The post is a bit dated, the CPT codes have changed since then, and the reasons to not take insurance have increased.  Many other doctors don't take insurance now, though psychiatry remains the number one specialty where doctors don't participate in health insurance plans.  This is an updated version of that same post.

Many psychiatrists in private practice don't participate with insurance insurance panels. They require the to patient pay  and then the patient has the option to submit a claim to his health insurance company as an "out-of-network" service,  and reimbursement is made directly to the patient. This may mean that the patient has a higher co-pay and deductible, and the hassle of doing the paperwork.  It also means that if the insurance company does not send reimbursement, that the cost is incurred by the patient, the doctor has still gotten paid.  If a patient sees a psychiatrist in his network, he pays the deductive and co-pay and the hassle of getting the rest of the money falls on the doctor.  Now the overall expense of an out-of-network psychiatrist may or may not be lower -- some plans have excellent out-of-network coverage -- but any way you look at it, the hassle and financial risk are less if a patient sees doctors who participate with their insurance.

Because many psychiatrists do not participate, it means that access to psychiatric care may be limited to those who have the money to pay up front,  and the wherewithal to stick their statements into an envelope and send them to the insurance company-- after they've called a separate managed care company, gotten pre-authorization, and had Dr. Shrink submit a treatment plan. They must assume the financial risk that the insurance company might find some reason not to reimburse.  Over on PsychPractice, our colleague has a post up about an insurance company that lost the claim, then wouldn't pay it because it was then submitted late, and then wanted the psychiatrist to provide references as to why out-of-network service is necessary.  It's about the number of hoops, how high one must jump, and whose going to do the jumping.

 By not accepting assignment, the doctor has greater control about what he is  paid, but the patient supply becomes limited in a way that restricts access to care.   Patients who want the financial and logistical benefit of remaining in their network are often surprised to find that it's difficult to find an in-network psychiatrist (even though the insurance company often has a large list of dead providers) or that those psychiatrists aren't taking new patients, or that they see patients for brief med checks but not for psychotherapy, or that it's hard to find a psychiatrist who feels warm and fuzzy enough. From the patient's point of view, it's not fair. There's a reason for this: it's not fair.

So why don't all shrinks accept assignment, why aren't they lining up to be members of insurance networks who would funnel lots of patients their way? Let me tell the story from the psychiatrist's point of view.

  •  If a psychiatrist doesn't accept assignment, s/he sets his own fee-- generally what the market will bear. This one is easy, everyone understands wanting more money, and the insurance company fees are often less that what a psychiatrist can charge if he does not participate. 
For some psychiatrists, that's the bottom line. For many, however, it's about much more: the paperwork and the freedom to practice psychiatry as he wants.

  • If the psychiatrist accepts assignment, he agrees to practice according to the terms of the insurance company. He sees the patient and collects the copay. Maybe it's a flat $30 co-pay, after a certain deductible. Maybe it's 80% for the first 5 visits and 70% for the next 5 visits and 60% for all the visits after that oh but the patient is only covered for 25 visits a year and the psychiatrist has agreed not to balance-bill as part of the deal. I don't know what happens if the patient needs a 26th appointment, I believe the doc eats the fee or simply doesn't offer the extra sessions. At any rate, the doctor now needs to figure out how much the patient has to pay and it's his responsibility to collect this. Oh, but it's not 80%/70%/60% of HIS fee that the insurance company will pay, it's 80% of what the insurance company has decided is Usual & Customary Rate (UCR) which is set by the insurer. And while it might be a piece of cake to calculate if the the UCR was say $100/appointment and the patient paid $20 and the insurance company paid $80, but it's a pain in the neck if the UCR is $97.84/ session and you have to keep count of the sessions and figure out the percentages. Should I mention that different insurance policies by the same company can have different payment rates so someone has to call for each patient, verify the insurance, find out the terms, co-pays, deductibles, and this involves sitting on hold and dealing with assorted prompting menus. Did I mention that some patients have two insurance policies?  When I accepted Blue Cross in the early 1990's, they would send me checks for $12.44 for 50 minute sessions.  I never did figure that one out, nor could my three billing secretaries explain it. 
  • While many psychiatrists in private practice are able to manage their practices without secretarial support, a psychiatrist who practices in-network usually needs a secretary, an overhead expense his I-don't-accept-assignment friends may or may not want or need. And he now has to have an office big enough to accommodate secretarial space. I'll also tell you that while the secretary is paid an hourly fee, his ability to get paid is only as good as her motivation to follow through on dealing with the insurance companies, refiling denied claims, clarifying primary versus secondary insurance and getting the amount of the co-pays correct.
  •  And if the insurance company finds a reason not to pay, the doc is stuck--he can't bill the patient, he's just out the time/money. For a psychiatrist who does psychotherapy and sees 8-11 patients/day at an insurance company discounted fee, doing work that does not get reimbursed is a problem. A doctor may decide he can afford to take on some patients at reduced fees, but it's infuriating to be subsidizing an insurance company because the forms were filed with something coded wrong, or because the insurance company lost them. 
  • Increasingly, insurers have requirements for how the doctor practices.  Medicare has it's 1.5% fee cuts for doctors who don't e-prescribe.  They have incentives to get doctors to figure out "meaningful use."  There are fee cuts if PQRS codes are not done.  They still take paper claims, but will likely soon require electronic submissions.  Every segment of these mandates requires a large investment of time and often money.  Really?  Click on the "meaningful use" link I  provided and try to read the entire page.  Here it's hard to figure out where the hoops are, much less how to jump through them.

So  why does any psychiatrist accept insurance?  Some doctors don't get enough referrals without participating, some are simply afraid they won't so they don't drop out of networks, others practice in areas where people simply can't afford to take insurance.  In some areas of the country, this is just not a mind set: everyone takes insurance, and psychiatrists just do med management.

  • Insurance companies pay reasonably for short appointments with a psychiatrist.  A psychiatrist who sees two patients in an hour makes more than a psychiatrist who sees one patient in an hour, and often the insurance companies-- perhaps eager to encourage their policy holders to seek psychotherapy with a cheaper clinician-- will pay a reasonable amount for a shorter session-- perhaps they make this worth doing. A psychiatrist who can see four or five patients in an hour and who has a secretary and has a system in place can do well financially by billing insurance companies, but it does require volume.  A psychiatrist who sees patients for hour-long sessions will be disadvantaged and that's why in-network psychiatrists don't usually provide psychotherapy.  

What you don't hear when you read about how psychiatrists don't take insurance is that we still like what we do.  I still have a job where I spend each hour listening to patients without interruption, I then put a note in a real paper file in a metal filing cabinet.  I just read that the average primary care doctor spends 2/3 of their time on clerical work.  I'm happy to say that I spend the vast majority of my time in e-free sessions with my patients and I'm hanging on to that for as long as I can.  But it's not just about the money, it's about three things: the money, avoidance of mountainous paperwork hassles, and the the freedom to practice psychiatry in a rewarding way.

----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.

Please Don't Batter the Shrink

Shrink Rap - 12. January 2014 - 11:41

When I was a child, I lived across the street from a neurologist.  The neurologist shared his office with a psychiatrist, and I was told that one day, a patient walked into the office and shot the psychiatrist.  Last week, in Italy, a psychiatrist was stabbed to death by a patient.  We don't think about how dangerous it may be, but being a shrink has some risks.  Actually, being a person has some risks, and in Baltimore, fourteen people have already been murdered this year, more than one per day.

With that as a prelude, I was on vacation briefly in December; a quick trip to visit family.  In the hotel, I reached for my phone and looked at my Twitter feed.  After all, it's one of the ways I get the news.  Only I'm thinking of "news" in terms of local and federal levels, not personal information about my friends.  I read a tweet from Clink, and realized, oh my, she's been assaulted by a patient.  This she puts out on Twitter.   It was late, I texted, and in the morning I called.  "Are you okay?"  She was okay, and she still is okay, a little shaken.  I'm glad Clink is okay and if you'd like to read her perspective  on it, she wrote about on Patient Assault -- an insider's view over on Clinical Psychiatry News.  ----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.

Let's Have a Task Force!

Shrink Rap - 11. January 2014 - 11:26

I'm going to do a little problem solving here. 

In the Washington Post yesterday in Virginia Doesn't Need Another Mental Health Task Force,  Pete Earley writes:

Virginians should be embarrassed and angry that a newly appointed state mental health task force convened Tuesday in Richmond. It is the 16th task force asked to investigate the state’s mental health system.
If you click through to hit the link, you'll note that this 16th task force on mental health has 36 members.  Politicians love task forces, it's a way to look like something is "being done" without actually doing anything.  So now 36 people, presumably on someone's payroll, have to coordinate their time to be at these meeting, write reports, and in this case, reinvent the wheel.

I'll point out two other quotes from Mr. Earley's commentary, and then I'm offering my suggestions on how to fix the problem to the State of Virginia at no cost, here on my free blog, and all 36 of those people can go home and spend quality time with their families.


Virginia’s inspector general warned in a May 2011 report that 200 people were turned away from hospitals during one 12-month period because of a lack of beds, even though the patients were considered a danger to themselves or others.

Virginians must look at the big picture. After the Virginia Tech shootings, our task force lowered the criteria for involuntarily committing someone into a hospital. While a positive step, this has proved ineffective because there are not enough hospital beds. Meanwhile, 80 people in state hospitals are ready to go home but can’t leave because there is no affordable housing in their communities. It costs $590 per day to keep those patients in a hospital. It would cost $120 per day for them to live in a community setting. You can’t fix one tire and expect a car to run if the other three are flat.
So in my state (Maryland), the average length of stay in a psychiatric unit is roughly 7-10 days.  For certified patients, it gets a little longer, more like 14 days.  In Virginia, we're told,  200 patients/year are released from ER and I'll assume they have similar lengths of hospital stay.   Distributed evenly over the year, we're talking roughly 7.67 hospital beds if each of those patients stays for a full 14 days.  Let's be generous here; let's say that you need a few more beds in case the patients don't distribute their admissions evenly through the year, so let's give the State of Virginia 12 extra beds for their population of 8.2 million.  It seems they need one new psychiatry unit in a general hospital, or one extra bed in 12 units around the state. All this fuss for a dozen, or less, hospital beds?   

But Mr. Earley also points out that the state could save money by moving state hospital patients who are ready for discharge to a community setting, so presumably they don't even need to build a new facility, they just need to move a dozen patients to a community setting.  I imagine the cost to run a state hospital is a fixed cost, so the total cost of doing this is the $120/day/patient cost of moving those 12 patients: or roughly $500,000 year.  Chump change to get treatment for 200 dangerous people.

One last suggestion to Virginia: change the law requiring a hospital bed be found within 6 hours of a judge issuing an order for hospitalization.  I'm imagine the law came about because people were left in ERs for days at a time, as they are here in Maryland, so a humane requirement to move the process along is fine, but a law? And six hours?   In that time, I'll assume the police have to get the patient, transport him/her to the ER, get through triage, clarify health insurance, do vital signs, lab work, medical clearance, psychiatric evaluation-- including discussions with family and the patient's doctor, and locate a bed (a process that entails 'calling around' (--might I also suggest they set up a Google Form that hospitals could update a few times a day with their bed availability?)-- in six hours.  Maybe the patient gets brought in and doesn't need hospitalization? -- There was a misunderstanding, or he's acting strangely because his blood sugar is low, or she ran out of medicine and just need to be restarted on it....but those things take more time.  Sometimes, after a patient calms down (-- having the police grab someone makes everyone angry) and gets a thoughtful look and perhaps medications, then a few hours for the medicine to take effect,  and the patient may agree to sign in voluntarily. As I noted above, this makes for a shorter average length of stay.  Other times, the patient can be sent home, but a psychiatrist in an emergency room can't know that until he's had a chance to observe the patient for a while,  and to clarify what the outpatient follow up might be and what setting he is sending the patient home to.  

 I don't know that the laws we have in Maryland are any better than those in Virginia.  We also have problems with access to care, both inpatient or outpatient, and we also have our own mega-task force : the Continuity of Care committee.  Sometimes I wonder if common sense could take care of some of these issues, but as Pete Earley notes, it requires taking a stand and then moving forward, and change is hard.  I am starting to think that in Virginia it sounds to be very easy to get a gun and very hard to get mental health care.


----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.

Let's Keep Guns Out of the Hands of.....

Shrink Rap - 8. January 2014 - 21:24

First, the quote of the day,  an explanation to follow:

--"I'm a gun owner.  It happens."
President Obama has renewed his commitment to keeping guns out of "the hands of the mentally ill."  See the story in Bloomberg here. 

In my world, I'd like to keep guns away from most people, but no one asked my opinion.  I realize there was a reason for the Second Amendment and that no one is going to go along with a repeal of the right to bear arms, so instead of designating people as targets for legislation based on having received medical treatment for psychiatric disorders, I'd like to talk about who is not safe with a gun.  I'm more interested in behaviors than labels.   

Who shouldn't be allowed to own guns:

People who are violent, impulsive, and who exhibit poor judgement.  I may be alone in this belief.

~Anyone found guilty of a violent crime, even one that is minor in nature -- a bar fight, an assault.  Why? Because it shows someone is capable of violence on a level that comes to the attention of authorities.

~Anyone with a history of a suicide attempt that is lethal enough to require a medical admission.  
Most firearms deaths are suicides not homicides.  Even if the admission is for an overdose, someone who is a proven danger to themselves should not have a gun.

~People with substance abuse problems -- intoxication leads to impulsive acts and leads people to do things they wouldn't otherwise do.  Obviously, everyone who has a few too many isn't dangerous, but our state law prohibits "habitual drunkards" from owning guns.  While people are reported to the NCIS database to prevent gun ownership if they've been hospitalized on a psychiatric unit for 30 days, you can go into rehab repeatedly without being reported.

~People who are committed to a psychiatric unit for being dangerous.  I don't mean everyone who is admitted against their will, but if it goes to a hearing and a person is found to both have a mental illness and to be dangerous and is unwilling to get treatment, then the court proceeding should include the loss of a right to own a weapon.  (This may make me unpopular, but it seems a reasonable level for safety).  

~People who reside with anyone in the above categories.  If you can't own a gun, what difference does that make if your sister leaves hers lying around.

~Anyone with any firearms misconduct at all. Period. If you're not able to be responsible with a weapon, you shouldn't own one.  Which brings me to the quote of the day above. It was made by Representative Leslie Combs, a state legislator in Kentucky after she accidentally discharged her legal gun in her office in the state's capital annex building today.  Apparently there are no charges being filed because it was an accident and no one was hurt, but really....if you fire a gun in a state capital even once, isn't that grounds to say someone might not be safe with a firearm?  If it were not a lawmaker, would this be tolerated? 

"I'm a gun owner.  It happens."  Really?  I'm astounded. 

----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.

Things That Make Me Crazy

Shrink Rap - 5. January 2014 - 10:27

I sometimes think I live in a tight little fantasy bubble where I want life to make sense and be fair.  I want it to be an uncomplicated place where, when resources are limited, we assess the problems and direct the dollars to things we know will efficiently fix the problems.  I'd like us to use our public health  dollars to feed hungry people, to house those without some place warm to stay, to help those in need learn strategies and get jobs so they can help themselves, and to provide health care to those who are ill.  In cases where there are big-picture items that lead to devastating consequences and enormous costs to society, I'd like us to target the causes with early interventions that are known to be effective: so measures to prevent drug/alcohol/tobacco abuse, better and more available drug treatments, and more resources dedicated to early education so that everyone gets the skills they need to earn a living and grow up to be a taxpayer.  

Instead, through some mix of politics and medicine, there are these untested (or poorly tested) ideas out there that cost billions of dollars and money gets diverted away from being used for the direct good of the people.  Maybe I'm wrong-- I'm sure there are plenty of people who disagree with me and think that these changes are important and will make the world a better place -- so by all means, feel free to comment. tell me why I'm wrong, or do add to my list.  It's a little of 'one guy unsuccessfully tried to blow up a plane with his sneakers so millions take off their shoes for screening every day.'  The cost is phenomenal, but I do have to  admit that no planes have been blown up with shoe bombs since, and if my child was on a plane that didn't explode, then the cost to society was worth it, but it's not a very "public health" way of thinking.  But you have to wonder what we're giving up when we put a lot of time, money, or resources towards low-probability events or towards paperwork for the sake of paperwork.  In no particular order:

Dinah's List of Aggravating Diversions from Productivity in 2013

  • CPT codes that force psychiatrists to differentiate "medical care" from psychotherapy with rate changes depending on whether the psychotherapy component takes 52 minutes or 53 minutes or the session, and creates 15 different options for coding a single psychotherapy session.
  • 68,000 ICD-10 codes for the purpose of diagnosis/billing. Really?  ClinkShrink will be thrilled, code Y92146 is for getting hurt at a prison swimming pool.  Prisons have swimming poolsAnd Y92253 is for being hurt at the opera, so Clink and Jesse can both rest assured that injuries they may incur can be coded. This helps us how?  And, no, US prisons don't have swimming pools, but why should that stop us from having codes?
  • Legislation -- complete with the cost of databanks, means for reporting to such databanks, and the cost of enforcement -- to keep the poorly-defined 'mentally ill' from owning guns when there is no such effort to keep the family members or roommates of those people from owning guns, and there is no such effort to keep guns from those who are known to be dangerous if they are not mentally ill.  The laws in Maryland also include 'habitual drunkards,' -- but there is no provision to report those who goes to detox/rehab or have a second DWI/DUI from having a gun. 
  • Continued support of the Second Amendment as interpreted rather widely, despite 40,000 gun deaths/ year, some of them innocent small children. "A well regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed."  I'm just not sure that the founding fathers foresaw a society of drug addiction, rampant suicide, and a country with a firearms death rate beyond any other country in the world.  There was slavery when the second amendment was written, and I don't think the amendment included slaves, so clearly the 'right of the people' did not mean all people, or include assault weapons that did not yet exist.  The second amendment has become an impenetrable devotion -- in Maryland's it's some state legislator's main forum -- as if it were a religious belief.  And people with mental illnesses have taken the blame for all inappropriate uses of guns.  See yesterdays Bloomberg Report for our President's pronouncement, and by all means, read the comments.   
  •  Meaningful use -- a government/Medicare phenomena that creates a tremendous amount of work for physicians that does not seem to directly improve patient care (correct me if I'm wrong), and if it does, it doesn't improve patient care/outcomes in a way that warrants the time, and expense.  I don't really know what Meaningful Use is (such details never stop me from ranting), but I know the government will give me money if I'll convert to electronic records and use it in a particular way.  Otherwise, for every Medicare  patient I see, I must charge a lower fee if I don't use e-prescribing (which is not conclusively shown to improve patient outcomes) a certain percentage of the time, and that in 2013, to prevent an drop in my fees, I needed to put a PQRS code on one patient's insurance claim form.  I could not figure out what that meant, so I asked an APA assembly member who runs a hospital.  After two  separate half-hour phone conversations, one in-person meeting, and I have no idea how many hours of his time, he provided me a list of options which included things like "medications not reconciled, reason not given."  I opted to list on one patient's claim a code indicating he was not a tobacco user, and I'm told this was good enough to keep my fees from dropping 1.5% next year.  What's meaningful about this?
  • CRISP/Government portals of patient records collected without patient knowledge/permission.  These may be very helpful for emergency care in crisis situation,  and perhaps they allow for data/outcome collection that will be used for outcomes research, but they cost a lot of money and after the NSA scandal, are we all comfortable with the government keeping our health records without our expressed permission?  Are we sure our health information won't bounce back at us in unwanted ways?
  • Hospitals that spend HUNDREDS OF MILLIONS OF DOLLARS to replace existing, function, Electronic Medical Records when there are people sleeping on cardboard boxes outside their doors, and when such medical records increase the amount of time clinicians spend with computers and decrease the amount of time they spend with patients -- and don't necessarily decrease medical errors.  This feels wrong to me  on so many levels: there are shortages of physicians and we're diverting their attention to clicking through screens and checking off boxes that have nothing to do with the care of that particular patient, adding hours a day to physician workload, promoting physician burnout, and diverting funds to this project that could be used to pay for health care for human beings.
  • Government-run health insurance exchange(ACA) websites that are basically unusuable and create too much frustration for the average person --especially the average person with medical or psychiatric issues-- to work efficiently.  One of my patients was blocked from signing up because he forgot his password, and the recovery question involved his pet's name, only he's never had a pet and was locked out of the system. 
  • Hospital medical records that afford no privacy because thousands of people have access to them and patients can not opt out, other than to get care at another institution.  But if you want information about a patient from another institution, with the patient's permission, barriers are put in place to make this next to impossible.  I recently requested records from a local hospital ten minutes from my office, and two weeks later they sent me a form saying that the authorization my patient signed was not good enough, it had to be signed on their specific form.  How crazy is this?  Perhaps it's because that hospital's administrator was so busy looking up my PQRS codes that he wasn't updating their information release policies.
  • That my state is proposing to spend money on programs to increase cultural awareness and competency on number of measures when people need food/housing/healthcare/job training.  I'm all for treating people respectfully, but maybe it would be cheaper to fire those who are demeaning to others rather than to set up training programs to make them 'culturally aware.' (Please forgive my cynicism, in a world where everyone is fed, housed, has healthcare, heat, education and jobs, I'm all in favor of programs to increase sensitivity to cultural issues).
  • "That my state is proposing to add Assisted Outpatient Treatment (read: forced care) when we don't have enough information to know if this really works without other services in place.  We don't have  enough resources to care for people who want care, and this will entail forcing people to take medications that are known to have detrimental cardiovascular effects in some people,  distressing side effects in others, and may include forcing care on people when that care does not decrease their symptoms. If I thought the legislation was truly about getting care for the very sickest of people -- those 'dying in the streets with their rights on' -- I would be in favor, but I believe it's a "do something" measure to address spree shooters and has been tied to federal funding. 
Thank you for letting me rant.  That's what this was, and I appreciate it.  I feel much better now. 

----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.

The "Mentally Ill" Bucket

Shrink Rap - 3. January 2014 - 19:48

Dinah wants me to post more, so she asked me to put up my comment to her post on Results of the Survey on Who are the Mentally Ill. (If you didn't see the original survey, it is here.)

So, here's my comment. But I'll begin with the limerick...
There once was a man from Nantucket
With a thought that was quite a nugget.
   "The world is round," he exclaimed;
   Which confirmed he's insane.
So they placed him in "the mentally ill" bucket.
When I first saw this survey, I told Dinah it was a terrible survey and that she should take it down, because by even asking people 'who are "the mentally ill" ', it lends credence to the concept that one can put everyone with a mental illness -- or even more simply, a "mental health problem" -- into the same bucket.

This phrase -- "the mentally ill" -- promotes the stigma, stereotypes, and myths, that many people have about mental health problems of any sort. It also is a phrase that dehumanizes people by labeling them by their disease. "People first" language is preferred. "The person with schizophrenia", not "the schizophrenic."

Labeling people as their disease (or illness or symptom) dehumanizes people. They are no longer a person, but a disease. "Diabetics" don't seem to be bothered by this so much, but in psychiatry our patients continue to face discrimination, stigma, misunderstanding. By using these terms -- as many politicians and journalists still do -- it uses language to convey that it is okay to define people as their disease, that this is the most important thing to know about them. By breaking them down into people with, it is harder to say things that apply to all of them.

"The mentally ill are violent."
"People with mental illnesses are violent."
It is much easier to counter the last one (how can this apply to every person with a mental illness?), but the first is more fear-mongering, and stops you from thinking critically. Even so, these myths continue. (Only 5% of violent attacks are caused by people with a mental illness.)

Are there surveys about Who are the Physically Ill? Or, Who are the Cancerous? Or the Blacks? The Jews? The Gays?  You get my point.  Unfortunately, the survey did not have responses that said, "None of the above, because people are not defined by their illness and to say otherwise would be stigmatizing."

So, now that I have declared my bias against this term and this survey, I will share my thoughts on the results, anyway. The answers suggest that people are all over the place about what characteristics they deem necessary to put others into "the mentally ill" bucket. The most consistent themes seem to be those of persistence and severity. The longer that one has a condition, and the more severely it affects one's life and relationships, the more likely one is placed in the bucket.

I was also surprised to see bipolar disorder scoring almost as highly as schizophrenia; same with mood stabilizers like lithium scoring right up there with antipsychotics.

  * * *

Since there were already some comments to my comment, I'll address some here.
Liz used to feel hopeless and hate herself when accepting the "borderline" label. She has since changed her perspective and feels better. Good for you.

Three people (Not me and two Anonymi) thought the survey responses didn't fit their answers; "pretty impossible to answer because so many of the questions required more information." While I agree, I have come to see that this forces people to address their assumptions. This is good for the stigma discussion.

Dr Reidbord was quicker to get this than I was, finding the results revealing that this term is used in a variable and nonspecific way, often used "when the speaker can't express himself, for either linguistic or political reasons, more precisely."

I thought the wisest quote was from Borderline, who said:
"It's easy to pigeon hole and hard not to sometimes."   * * *

I googled "mentally ill bucket" and found only ten links. The best is "There are no excuses" from K. Wolf-Madison, who wrote more eloquently along the same line as I do above. "The marginalizing of the mentally ill with those words continues to damage us all."

----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.

Results of the Survey on Who Are the Mentally Ill?

Shrink Rap - 2. January 2014 - 14:11

Thank you to everyone who participated!
The survey was published on Shrink Rap from
 December 10, 2013 - December 22, 2013.

Respondents were solicited through social media, including blogs, listservs, Facebook, and Twitter.  Respondents were not limited to the United States. 

Please note that the survey was not validated.  The data below was pasted directly from the Google "Summary of Responses" with no analysis or interpretation.
SummaryAnyone who has seen a therapist is mentally illTrue172%False67698%Anyone who has been in psychotherapy with a psychiatrist is mentally illTrue619%False63091%Anyone who takes a psychiatric drug prescribed a by primary care doctor is mentally illTrue13420%False55180%Anyone who who takes a psychiatric medication prescribed by a psychiatrist is mentally illTrue25237%False43563%People are mentally ill if they take any of the following medicines:Anti-depressants, for example Prozac212
Daily anti-anxiety medications that may be addictive, for example Xanax (medications in the benzodiazepine class)233
Occasional, as needed medication for anxiety, for example Xanax, Valium, or Ativan83
Medicine for Attention Deficit Disorder, for example Adderall120
Mood stabilizers, for example Lithium or Depakote 410
Older antipsychotic medicines, for example Haldol or Thorazine439
Newer anti-psychotic medications, for example Abilify, Seroquel, or Risperdal424
Sleeping pills, for example Ambien, Trazodone, or Ativan36
I am not familiar with any medications and have no opinion49
The mentally ill are people with the following disorders:Attention deficit disorder (ADD)136
Adjustment Disorder116
Generalized Anxiety230
Panic Disorder282
Phobias 194
Social Anxiety Disorder250
Bipolar Disorder534
Schizophrenia/Schizoaffective Disorder620
Brief Reactive Psychosis324
Obsessive Compulsive Disorder382
Borderline Personality Disorder441
Antisocial personality disorder394
Pedophilia 409
Conduct Disorder or severe behavioral problems in a child or teen255
Substance Abuse Disorders275
Compulsive Gambling253
Intermittent Explosive Disorder (repeated rage episodes)381
Gender Identity Disorder119
I am unfamiliar with any psychiatric disorders and have no opinion15
Someone who has voluntarily been hospitalized on a psychiatric unit is mentally illTrue30044%False37856%Someone who has been involuntarily hospitalized on a psychiatric unit is mentally illTrue48070%False20430%People who hear voices or have delusions are mentally illTrue61289%False7611%Anyone who has had a serious suicide attempt is mentally illTrue34050%False34350%A person whose behavior is volatile, erratic, and makes it difficult for them to maintain relationships and/or employment is mentally ill, even if they have not seen a professional to get a diagnosisTrue44966%False23234%Someone who had treatment for a serious psychiatric disorder years ago and is now doing well, but still takes medications, is mentally illTrue36453%False31947%Someone who had treatment for a serious disorder years ago, but no longer needs treatment and is doing well, is still mentally illTrue8913%False59987%Anyone who gets long-term disability payments from the government for a psychiatric disorder is mentally ill, regardless of whether they have symptoms or take medicationsTrue18527%False49873%I personally take, or have taken, psychiatric medications and/or I have been hospitalized on a psychiatric unit and I think of myself...Yes, I consider myself mentally ill17325%No, I do not consider myself mentally ill19127%I used to consider myself mentally ill but I no longer do548%I have never taken psychiatric medications and I have never been hospitalized27840%
----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.

Depression, the Secret we Share -- A TED Talk by Andrew Solomon

Shrink Rap - 30. December 2013 - 9:18

If you've ever been depressed, if you've ever known anyone who has been depressed, if you've ever wondered what it's like to be depressed, or if you just want to listen to a wonderful talk,  do listen to Andrew Solomon's TED talk.----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.

Psychiatry Articles on the Web

Shrink Rap - 29. December 2013 - 8:00

There have been a number of articles I've wanted to mention lately.

In the New York Times:
When the Right To Bear Arms Includes the Mentally Ill

In the Wall Street Journal, set in our own Maryland:
For the Mentally Ill, Finding Care Grows Harder


Representative Tim Murphy Instroduces Mental Health Legislation

From the StarTribune:

Minnesota Security Hospital: Staff in Crisis Spreads Turmoil

In Atlantic Monthly, a poignant story about one man's battle with anxiety:

Surviving Anxiety

And finally, on Salon, it's from nearly two years ago, but I ran across Linda Gray Sexton's account of being suicidal and found it to be moving:

In the shadow of my mother's suicide----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.

Common biology shared in schizophrenia and bipolar disorder - The Almagest

Maryland Psychiatry - 28. December 2013 - 6:42

The Almagest

Common biology shared in schizophrenia and bipolar disorder
The Almagest
“We have known for a long time that the clinical symptoms are shared substantially between the two conditions, but when you look at the biology, these illnesses also blur into each other,” said Godfrey Pearlson, professor of psychiatry and neurobiology ...

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Assisted Outpatient Treatment?

Shrink Rap - 27. December 2013 - 23:03

Happy Holidays, everyone.  Blogging has been a little slow here at Shrink Rap as the Shrink Rappers overdose on cookies and get caught up in all the usual holiday stresses that get to everyone.
I've heard rumors that in the coming 2014 Legislative Session in Maryland a bill may be proposed to make Assisted Outpatient Treatment (AOT) part of the landscape.  As it stands now, we are one of the few states that does not have AOT, or forced treatment, for outpatients, outside of the forensic system for those on conditional release after having committed a crime (often a violent crime).

Since Maryland doesn't have AOT, I have no experience with it.  Perhaps it's a good idea; I don't believe it's humane to leave people living in the filth and cold on the streets if they have a psychotic illness that could be treated.  But I'm also well aware that treatment has side effects for some, and limited efficacy for others, and I worry that forcing people to get care in an already strained system is not the same as forcing them to get thoughtful, individualized care, with a spectrum of treatments being offered.  

So I'm staying out of the discussion at this point, as all I can say is that I don't know what the right thing is to do. I do know that people have strong opinions.  

If you live in a state with Assisted Outpatient Treatment, and you've been a part of the program, then I"d love to hear your comments.  If you have a family member who gets AOT, or are a doctor involved with such treatment, then I'd love to hear your opinion as.  If you've never personally been involved with forced outpatient care, even if you've been involved with forced hospitalization, then I'd like to ask you to hold your opinions for now.  I really  would like to hear from the direct recipients of these treatments.

Thanks so much!----- Listen to our latest podcast at or subscribe to our rss feed. Email us at mythreeshrinks at gmail dot com Our book is out now.

Psychiatric Consultant Helps Shape Care of Wide Range of Patients - Psychiatric News

Latest Psychiatry News - 27. December 2013 - 13:26

Psychiatric Consultant Helps Shape Care of Wide Range of Patients
Psychiatric News
Print. E-mail. Recipient(s) will receive an email with a link (good for 72 hours) to 'Psychiatric Consultant Helps Shape Care of Wide Range of Patients' and do not need to have Psychiatric News account to access the content. Your Name:* ! Example: John ...

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New Uses of Brain Imaging Get Closer to Clinic - Psychiatric News

Latest Psychiatry News - 27. December 2013 - 10:11

New Uses of Brain Imaging Get Closer to Clinic
Psychiatric News
For example, men with schizotypal personality disorder have reduced matter in a number of brain areas, Robert McCarley, M.D., chair of psychiatry at Harvard Medical School, and his colleagues have found. Brain structure abnormalities in girls with ...

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GADL1 gene variants predict response to lithium in Han Chinese - Clinical Psychiatry News Digital Network

Latest Psychiatry News - 26. December 2013 - 16:04

GADL1 gene variants predict response to lithium in Han Chinese
Clinical Psychiatry News Digital Network
They assessed 1,647 Han Chinese patients with bipolar disorder I who were treated at Academia Sinica, psychiatric departments of general hospitals, or psychiatric institutions across Taiwan. The investigators identified 294 patients who had received ...
Striking a Nerve: A Result Too Good to Be True?MedPage Today

all 2 news articles »
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APA Successful in Attaining Higher Work Values for Psychiatry - Psychiatric News

Latest Psychiatry News - 26. December 2013 - 15:53

APA Successful in Attaining Higher Work Values for Psychiatry
Psychiatric News
For too long, this has especially been the case for psychiatric services. Mental illness is a health care disparity, and mental health care has been stigmatized and undervalued, as have been the physicians who provide it. The result has been ...

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Psychiatry's Jeremy J. Clark receives Presidential Early Career Award - UW Today

Latest Psychiatry News - 26. December 2013 - 12:39

UW Today

Psychiatry's Jeremy J. Clark receives Presidential Early Career Award
UW Today
The White House has announced that Jeremy J. Clark, assistant professor of psychiatry and behavioral sciences, is among this year's recipients of a Presidential Early Career Award for Scientists and Engineers. Jeremy Clark studies the neurobiology of ...

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Calls to expand firearm background checks beyond mentally ill - Charlotte Observer

Maryland Psychiatry - 25. December 2013 - 11:43

Calls to expand firearm background checks beyond mentally ill
Charlotte Observer
“We're trying to reframe the approach to be more about individual assessment of risk and less about the categorical exclusion of people with mental health diagnoses,” Jeffrey W. Swanson, a Duke University School of Medicine psychiatry professor who ...

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CBT May Reverse Biological Changes in PTSD - Medscape

Maryland Psychiatry - 24. December 2013 - 13:24

CBT May Reverse Biological Changes in PTSD
The study shows "a definitive link between clinical improvement during psychotherapy, structural changes of the brain, and peripheral expression of genes responsible for stress response," Szabolcs Kéri, MD, PhD, of the National Institute of Psychiatry ...

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Maryland Undertakes Ambitious Effort at Early ID of Psychosis - Psychiatric News

Maryland Psychiatry - 23. December 2013 - 16:45

Maryland Undertakes Ambitious Effort at Early ID of Psychosis
Psychiatric News
The Maryland Early Intervention Program (EIP) is a collaboration among several centers and divisions within the University of Maryland School of Medicine Department of Psychiatry. These include the Maryland Psychiatric Research Center (MPRC); the ...

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